The prevalence of fetal alcohol spectrum disorders in rural communities in South Africa: A third regional sample of child characteristics and maternal risk factors

Abstract

Background: This study is the ninth cross-sectional community study of fetal alcohol spectrum disorders (FASD) conducted by the multidisciplinary Fetal Alcohol Syndrome Epidemiology Research team in the Western Cape Province of South Africa. It is the third comprehensive study of FASD in a rural, agricultural region of South Africa.

Methods: Population-based, active case ascertainment methods were employed among a school-based cohort to assess child physical and neurobehavioral traits, and maternal risk factor interviews were conducted to identify all children with FASD to determine its prevalence.

Results: Consent was obtained for 76.7% of 1158 children attending first grade in the region's public schools. Case-control results are presented for 95 with fetal alcohol syndrome (FAS), 64 with partial fetal alcohol syndrome (PFAS), 77 with alcohol-related neurodevelopmental disorder (ARND), 2 with alcohol-related birth defects (ARBD), and 213 randomly-selected controls. Four techniques estimating FASD prevalence from in-person examinations and testing yielded a range of total FASD prevalence of 206-366 per 1000. The final weighted, estimated prevalence of FAS was 104.5 per 1000, PFAS was 77.7 per 1000, ARND was 125.2 per 1000, and total FASD prevalence was 310 per 1000 (95% CI = 283.4-336.7). Expressed as a percentage, 31% had FASD. Although the rate of total FASD remained steady over 9 years, the proportion of children within the FASD group has changed significantly: FAS trended down and ARND trended up. A detailed evaluation is presented of the specific child physical and neurobehavioral traits integral to assessing the full continuum of FASD. The diagnosis of a child with FASD was significantly associated with maternal proximal risk factors such as: co-morbid prenatal use of alcohol and tobacco (OR = 19.1); maternal drinking of two (OR = 5.9), three (OR = 5.9), four (OR = 38.3), or more alcoholic drinks per drinking day; and drinking in the first trimester (OR = 8.4), first and second trimesters (OR = 17.7), or throughout pregnancy (OR = 18.6). Distal maternal risk factors included the following: slight or small physical status (height, weight, and head circumference), lower BMI, less formal education, late recognition of pregnancy, and higher gravidity, parity, and older age during the index pregnancy.

Conclusion: The prevalence of FASD remained a significant problem in this region, but the severity of physical traits and anomalies within the continuum of FASD is trending downwards.

Keywords: South Africa; child traits of FASD; fetal alcohol spectrum disorders (FASD); maternal risk for FASD; prenatal alcohol use; prevalence.

Figure 1.

Sampling Methodology for Prevalence of FASD in a Third Sample in South African Community

Figure 2.

Diagnostic Criteria for FASD. Reproduced with permission from Pediatrics, Vol. 138, Pages 3-4, Copyright © 2016 by the AAP

Figure 2.

Diagnostic Criteria for FASD. Reproduced with permission from Pediatrics, Vol. 138, Pages 3-4, Copyright © 2016 by the AAP

Figure 3.

Average Occipitofrontal (head) Circumference (OFC) by Measurement (cm) and Age-specific Percentile by Diagnostic Category for a Third Sample in Three Rural South African Communities

Figure 4.

Total Dysmorphology Score of FASD Diagnostic Groups and Normal Controls in Four Rural South African Communities: A Third Sample *Significant (p<.05) post-hoc Dunnet C Comparison was significantly different between diagnostic groups. Error bars = +/− 1 SE

Figure 5.

Proportional Distribution of Fetal Alcohol Spectrum Disorders (FASD) Diagnoses

Figure 6.

Case Ratio: Total Cases of Partial Fetal Alcohol Syndrome (PFAS) and Alcohol-Related Neurodevelopmental Disorder (ARND) per Case of Fetal Alcohol Syndrome (FAS)