Alcohol consumption is socially acceptable for individuals of legal drinking age. However, drinking during pregnancy is harmful and can lead to irreversible foetal cognitive and developmental issues. These are collectively known as foetal alcohol spectrum disorder.
The disorder may include foetal alcohol syndrome – the most serious of these abnormalities – as well as partial foetal alcohol syndrome. It can also include alcohol-related neuro-developmental disorders and birth defects.
Common risk factors associated with the disorder include low socioeconomic conditions, a low level of education, and harmful patterns of alcohol consumption. In South Africa, some alcohol abuse is believed to be rooted in a “dop" system. This is a practice in which farmworkers' wages were paid using alcohol beverages. Although this practice has been abolished, its lingering effects still influence South Africa's drinking patterns.
South Africa has the highest recorded prevalence of foetal alcohol spectrum disorder in the world. The prevalence rates range from 29 to 290 affected children per 1000 live births. The rates vary a lot across the country, with the Western Cape province recording the highest. Australia could be considered to have the second highest recorded prevalence in the world with 194.4 affected children per 1000 among Australian Aboriginals.
The South African government's policy responses to this problem have been inadequate. We conducted two pieces of research. In the first, we looked at a range of policy documents to identify clauses attributed to the prevention and management of the condition in South Africa. We supplemented this with in-depth interviews to help inform our recommendations.
We discovered that South Africa had introduced a host of new policy documents and there are a range of clauses in various guidelines. But the interventions are fragmented and don't speak to one another.
Another problem is that most of the current prevention and management approaches are informed generic statements embedded in different policy documents. The association of foetal alcohol spectrum disorder with other genetic conditions ignores the socio-economic factors associated with it. This means a comprehensive approach to addressing foetal alcohol spectrum disorder doesn't exist.
Our findings explain why the country has failed to make a dent in reducing the high rates. In our conclusions we recommend that the South African government should respond to the epidemic in a more coordinated and comprehensive way by designing a specific policy and targeted interventions.
What we found
The analysis we did indicated that 22 policy documents contained elements related to the condition. These included generic clauses focused on the regulation of liquor outlets, enforcement of liquor laws, and the general management of people with mental and educational challenges.
There were also clauses focused on creating platforms to improve the awareness, screening, identification and support for people with disabilities.
The in-depth interviews explored policymakers' perspectives on policies and interventions for the prevention and management of foetal alcohol spectrum disorder. We spoke to policymakers from the departments of social development, health and education. The interviews included officials working on issues related the problem.
Our research contributes to the debate around the prevention and management of the disorder in South Africa. It highlights the need for policymakers to develop a specific policy and to address the fact that current interventions and services are uncoordinated and fragmented.
The development of a separate policy is not a panacea to address the problem. It would, nevertheless, be a good starting point as it would lay the basis for a comprehensive approach. And it would help to address the social drivers of foetal alcohol spectrum disorders.
Current approaches have clearly not been effective.
The policymakers we spoke to expressed the need to develop a specific policy to address foetal alcohol spectrum disorder. But to be effective it should be multi-sectoral, family-centred and evidence-based. The policy should consider the needs of people with the disorder across their lifespan and their caregivers. It should also be clear about referral pathways and be based on a public health framework.
Such a policy should promote:
1) Awareness and education on the dangers of using alcohol during pregnancy in schools, clinics and communities.
2) The use of contraceptives and safe sex education to avoid unplanned pregnancies.
3) The training of service providers on how to counsel people with alcohol problems and diagnosis and management of foetal alcohol spectrum disorder.
4) The training and support of mothers and caregivers in the management of foetal alcohol spectrum disorder.
5) Skills training and empowerment programmes for people with the condition.
In the short term, the government can expand and link the clauses relating to foetal alcohol spectrum disorder that already exist in current policy documents. Existing services must be streamlined and current efforts to address the condition must be systematically evaluated to identify the gaps in services and interventions.
In the long term, South Africa needs to develop a separate policy for foetal alcohol spectrum disorder. This will facilitate the multi-sectoral collaborative approach needed to address the problem. Such an approach would go beyond managing the condition. Addressing foetal alcohol spectrum disorder would help the response to other societal problems. These include mental health problems, crime, intellectual disability and low levels of achievement in education.
The process of developing this policy must include a wide range of actors such as researchers, policymakers, service providers, people with the condition, their parents and caregivers.
We also argue that the South African government should replicate the success recorded in managing HIV and Aids. A specific policy was developed – based on goals set by the United Nations – that set a target known as 90–90–90. The aim is that by 2020 90% of everyone with HIV must know their status, 90% of those diagnosed with HIV must receive antiretroviral therapy, and 90% of people receiving antiretroviral therapy must be virally suppressed.
In addition, the government should learn from approaches adopted by other countries like Australia and Canada, which developed action plans that led to an increase in government funding. The increased government funding led to the expansion of prevention programmes and the establishment of specialist diagnostic service.
About the authors:
Babatope O. Adebiyi - Postdoctoral Researcher, University of the Western Cape
Anna-Marie Beytell - Senior Lecturer, University of the Western Cape
Ferdinand C. Mukumbang - Researcher, University of the Western Cape
Lizahn G. Cloete - Senior lecturer, Stellenbosch University