Predictors of alcohol use prior to pregnancy recognition among township women in Cape Town, South Africa

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Abstract

South Africa has the highest prevalence of Fetal Alcohol Spectrum Disorders (FASDs) in the world. The purpose of this study was to identify high risk factors associated with drinking alcohol prior to pregnancy recognition in 24 neighborhoods in the Cape Flats outside Cape Town, South Africa. An interviewer assessed risk among 619 pregnant Black/African women between the ages of 18 and 41 years. Logistic regression analyses explored factors associated with drinking alcohol post conception but prior to pregnancy recognition. Forced multiple logistic regression analysis revealed that drinking prior to pregnancy recognition was associated with being younger, single, having better living conditions, smoking, having a longer gestation prior to pregnancy recognition, having a greater number of sexual partners, and a higher incidence of intimate partner violence. Depressive symptoms tended to be higher among alcohol users. These risk factors were consistent with other research on the characteristics of South African women having children with a diagnosis of Fetal Alcohol Spectrum Disorders and/or of non pregnant women at high risk for an alcohol-exposed pregnancy. These findings highlight the need for women of child-bearing age to be routinely screened for alcohol use and its associated risk factors. Intervention efforts could be integrated into health initiatives already present in South Africa including the prevention and treatment of HIV/AIDS, tuberculosis, and malnutrition. Preconception care is particularly important since pregnancy recognition often occurs several weeks to months following conception and could be implemented by South African community health workers. These endeavors should facilitate national goals of healthier pregnancies and the elimination of FASDs in South Africa.

Introduction

It is well known that prenatal alcohol exposure produces a range of developmental deficits, collectively referred to as Fetal Alcohol Spectrum Disorders (FASDs) (Warren & Hewitt, 2009). The most severely affected children on the spectrum show a characteristic pattern of anomalies termed Fetal Alcohol Syndrome (FAS) which consists of prenatal and/or postnatal growth retardation, a unique cluster of facial malformations, and neuro developmental disabilities (Jones and Smith, 1973, Kodituwakku, 2009). Additionally, a substantial body of research has documented significant neurocognitive difficulties among individuals on the spectrum who do not meet full criteria for the syndrome but who fall along a continuum of disability and who are described as having Partial FAS (PFAS), Alcohol Related Neurodevelopmental Disorder (ARND), or Alcohol Related Birth Defects (ARBD) according to the diagnostic schema proposed by the Institute of Medicine (Hoyme et al., 2005, Stratton et al., 1996). The entire continuum of effects is estimated to represent at least 20 to 50 per 1000 live births in certain urban areas of the United States and some Western European countries (May et al., 2009).

Although recent data indicating that FASDs are more common in some populations throughout the world than previously thought, certain regions of South Africa are reported to have the highest measured prevalence rates of the disorder in the world (May et al., 2009, May et al., 2008). South Africa is a middle income country; however, it is also characterized by high levels of poverty and inequality. As a result of its apartheid past, conditions of adversity disproportionately affect the mixed race (‘Coloured’) and ‘Black/African’ (e.g., Xhosa) populations. Associated with adversity in these populations are high rates of infant mortality, HIV/AIDS, tuberculosis, and poor nutrition.

The most extensive and comprehensive series of studies of the effects of prenatal alcohol exposure on children in South Africa have been carried out in the Western Cape Province. These in-school studies of first grade primarily mixed race children living in rural and small town settings, reveal rates of Fetal Alcohol Syndrome as high as 41 to 74 per 1000 children (May et al., 2009). The addition of children diagnosed with Partial FAS reveals rates between 68 and 89 per 1000 in this population. Similarly high rates have been noted in two cities in the Northern Cape Province of South Africa reaching levels as high as 67/1000 for FAS and 100/1000 with the addition of the diagnosis of Partial FAS (Urban et al., 2008). These extraordinarily high rates demonstrate that alcohol exposure during pregnancy is a serious public health problem in South Africa.

Given the high prevalence rates of alcohol-exposed pregnancies in South Africa, studies have been designed to investigate various risk factors for having a child with a Fetal Alcohol Spectrum Disorder. The most comprehensive studies have been conducted in the Western and Northern Cape provinces (May et al., 2005, May et al., 2008, Urban et al., 2008) using retrospective recall of alcohol use during pregnancy. Using this methodology, mothers of children with the disorder were found to be older, were more likely to live in rural impoverished areas, had lower educational attainment, were less likely to be married, had higher parity, smoked tobacco, and suffered from poor nutrition with a lower body mass index (BMI). Other findings included higher levels of depression and living with a partner who had a drinking problem (May et al., 2008, Urban et al., 2008).

A recent population based study, examining risk factors for an alcohol-exposed pregnancy (AEP) in non pregnant women, revealed higher risk associated with living in a rural, as opposed to, an urban community (Morojele et al., 2010). One in nine women in the urban area (Gauteng) of South Africa and one in five in the rural area (Cederberg, Bergrivier, Swartland) were at risk of having an alcohol-exposed pregnancy by virtue of being current alcohol users, fertile, not pregnant, and not using effective contraception. For the rural women, risk factors included early onset of alcohol use, lower education level, being younger, lower parity, lifetime use of cannabis, smoking, and having a partner with a drinking problem. For urban women, predictors of risk included early onset of alcohol use, lifetime cannabis use, access to recreational facilities (that may include bars, taverns or shebeens), and smoking.

In order to guide appropriate social interventions, the aim of this study was to identify risk characteristics of pregnant Black/African women living in a peri-urban settlement area outside Cape Town. Many of these settlements are referred to as “townships.” In South Africa, the term “township” usually refers to the urban living areas that, under apartheid, were reserved for non-whites.

The theoretical framework for the study was based on Social Action Theory (Ewart, 1991). This model has been used to guide interventions to redress health problems that disproportionately affect certain communities such as substance and alcohol misuse among individuals in low income neighborhoods with high levels of health risks. A social action view emphasizes social interdependence in personal control of health-endangering behaviors. It further emphasizes that environmental, psychological, and problem solving activities are important to effect sustained behavioral change. Based upon this theoretical construct, and empirical findings from women with children with FASDs and women at risk for an alcohol-exposed pregnancy, we predicted that certain demographic, interpersonal, psychological, and living condition factors would be associated with reports of drinking alcohol prior to pregnancy recognition. Specifically, we posited that women who report drinking alcohol would more likely be smokers, younger, single, and to be less educated. Furthermore, they would report a higher number of symptoms of depression, would be more likely to have more sexual lifetime partners, to have a sexually transmitted disease, and to be exposed to higher levels of intimate partner violence.

The study was part of the initial phase of a randomized controlled screening and brief intervention program designed to provide a home-based model in which peer counselors (mentor mothers) provided psycho-educational interventions and ongoing social support to pregnant women who reported using alcohol during pregnancy. A larger aim of the research was to provide interventions to reduce the consequences of hazardous alcohol use, HIV/AIDS, and poor nutrition in order to improve child and maternal outcomes. This study is unique in that it was designed to assess women who were currently pregnant and consuming alcohol prior to pregnancy recognition. As such, data reported here include only an assessment of those factors associated with post conception alcohol use prior to pregnancy recognition.

Section snippets

Methods

Prior to participant recruitment, the research was approved by the Health Research Ethics Committee of Stellenbosch University (N08-08-218) located in Stellenbosch, South Africa and the Social Behavioral Institutional Review Board at the University of California at Los Angeles (G07-02-033) in the United States.

Alcohol and other substance use post conception

Of the 620 women invited to participate in the study, only 1 refused to participate resulting in a total sample size of 619. Of the total sample of 619 women, 27.0% (167/619) of women reported drinking post conception prior to pregnancy recognition on the Derived AUDIT-C (Table 2). Of that number, 72.5% (121/169) of women drank infrequently (<once a week) but when asked about heavy episodic drinking behavior, 61.2% (101/165) of women reported drinking four or more drinks per drinking day and

Discussion

Alcohol misuse continues to remain a problem in South Africa despite its prioritization by the Department of Welfare (1999). It is clear from the present study that over 1 in 4 women reported drinking alcohol post conception before pregnancy recognition. At pregnancy recognition, 71.1% of women reported that they had stopped drinking; however, of special concern is the fact that many women in the sample were unaware of their pregnancy status and were drinking well into the first trimester of

Conclusion

Alcohol exposure during pregnancy is a major public health problem in South Africa. As this study has demonstrated, there is a need for location-specific targeted intervention approaches identifying specific characteristics of women who could most benefit from prevention and intervention programs. Many of the risk factors identified in this study are interrelated and amenable to change through education and prevention efforts. Innovative and creative approaches are necessary along with improved

Acknowledgements

National Institute of Alcohol Abuse and Alcoholism, Grant 1RO1AA017104-01A1 (Rotheram-Borus, PI) supported this research.

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