Fetal Alcohol Syndrome In Africa

Betty Wakou

Childhood Nutrition NSCI 5373November 7, 2002

Prenatal Exposure to Alcohol Fetal Alcohol Syndrome (FAS)

• FAS –a set of birth defects– Growth deficiency (delayed physical growth and devt)– A characteristic set of minor facial traits—normalize with

growth – Mental and behavioral deficits (the effects of alcohol induced

damage to the developing brain are life long-devastating to children and families)

– Demonstrate difficulties with learning, memory, attention, and problem solving

– Problems with mental health and social interaction – Most common nonhereditary, most preventable mental

retardation

Prevalence Estimates of FAS

• Identified in France in 1968 and US in 1973• Between 0.5 – 3 per 1000 live births (Stratton et al., 1996)

• US rates: 0.33 to 2.2 per 1000 (Abel & Sokol, 1991; 1987)

• Developed countries: 0.97 per 1000 (Abel, 1995)

• American Indians 10 per 1000 (May et al., 1991)

• African Americans 2.29 (Abel, 1995)

• S.Africa Western Cape Province 39.2 to 42.9 per 1000 (May et al., 2000)

Mechanisms of Alcohol Induced Damage to the Fetus

• Multiple actions at different sites• Developing brain- development and function,

migration and survival of nerve cells• Embryonic cell layer that develops into the

bones and cartilage of the head and face-premature cell death

Diagnosis of FAS

• Identifies a small proportion of children• Easy when facial features and growth retardation are

present AND known maternal alcohol use in pregnancy

• Children may lack the characteristic facial defects and growth deficiency but still have alcohol induced mental impairments just as serious or more serious that FAS - ARND (alcohol related neurodevelopment disorder) and ARBD of the skeleton and organ systems

• A single measure cannot explain all the deleterious effects from alcohol exposure during pregnancy.

Skin folds at the corner of the eye

Low nasal bridge

Short nose

Indistinct groove between nose and upper lip

Small head circumference

Small eye opening

Small midface

Thin upper lip

Facial Features of FAS

Effects of alcohol exposure on growth

Head circumference

Birth weight

Length

Effects of alcohol exposure on growth and aptitude

Head circumference

Mental summary

score

Academic achievement summary score

FAS

• Reduced intellectual functioning and academic skills

• Deficits in verbal learning, spatial memory and reasoning, reaction time, balance, and other cognitive and motor skills

• Social functioning worsens during adolescence and adult hood with increased rates of mental health disorders.

Risk Factors Associated with FAS

• age >25 y • parity >3 • separated, divorced or never

married • high blood alcohol conc • binge drinking • long history of drinking • heavy drinking by male

partner or by any family member

• culture tolerant of heavy drinking

• low socioeconomic status • work in a male dominated

occupation, • unemployment, • social transience, • low self-esteem, • loss of children to other care, • sexual dysfunction, • use of multiple substances,

cigarette smoking

Alcohol Research In Africa

• Alcohol research in Africa is still in its infancy• There are few reliable data on alcohol consumption

and harm in general population • Drinking is on the increase in rural and urban areas • Drinking in the traditional setting is changing• New is drinking in bars and solitary drinking at home• Most literature is on surveys on alcohol use• Not many on drinking and its association with alcohol

problems.

Alcohol Drinking in S. Africa

• The legal ‘dop’ system- practice of paying farm workers in part with alcohol

• Institutionalized element for 300 years • Successive laws were in place• In 1961 an Act outlawed payment with alcohol

as part of the wage• Dispensing of wine as a ‘gift’ was not

addressed

Alcohol Drinking in S. A. West. Cape Province

• Alcohol consumption among farm workers is extraordinarily high

• Western Cape - drinking is about twice that of urban areas

• 50% of traumatic injuries are alcohol related and are 30% higher than in urban areas

Research Support

• National Institute on Alcohol Abuse and Alcoholism supported pilot studies in S. Africa

• Patterns of FAS occurrence, maternal risk, FAS characteristics similar to those in North American communities BUT higher

• May et al. (2000) measured 1st grade children

Epidemiology of FAS in S. African Community in the Western Cape Province

(May et al., 2000)

Objective: To determine the characteristics of FAS in S. African community

• Methods: - Active case ascertainment• Passive case ascertainment

– Birth records, registries, clinic-based systems, population-based initiatives

• Subjects: - 992 first grade pupils

Population Distribution

Population Distribution in Western Cape Province

0

10

20

30

40

50

60

Coloured Black White Other

Population

Diagnosis of FAS-Institute of Medicine

1. Facial and other dysmorphology

2. Diminished structural growth for age

3. Developmental (intelligence and social skills) delay

4. Maternal alcohol consumption

Results

• 40.5 - 46.4 per 1000 age 5-9y in schools• 39.2-42.9 per 1000 age specific community rates• 18-141x > US rates• Early stages of economic development • Low SES • Increased access to alcohol • Loss of folk and traditional culture

Factors Associated with Alcohol Consumption

• Patterns of binge and heavy drinking that produce FAS are associated with – rapid community change – detribalization – rural-to-urban transitions – progressions from traditional to modern (secular)

culture

• These changing social and cultural contexts, adaptation, coping and recreation are replaced with alcohol

FAS Risk Factors

• Advancing maternal age• High gravidity and parity • Early onset of regular drinking career • Quantity, frequency, and timing of maternal

drinking during pregnancy • Socioeconomic status• Rural residence residence on certain grape

growing, wine producing farms

Issues in Fetal Alcohol Syndrome

• Maternal alcohol use is controllable BUT• Prevention needs to use existing theory and

knowledge in the fields of health promotion and health education

• Pay attention to the risk factors that affect the target population’s use of alcohol and behaviors

Levels of Prevention

1. Primary - stop maternal drinking before it starts

2. Secondary- early detection and treatment of maternal drinking

3. Tertiary - to change behavior of high risk women

1. Universal – promote health and well-being of all people-use media, policy and environmental change

2. Selection – intervene in target populations at risk using trained health personnel

3. Indicated – intervene is women that drink