Social Determinants Affecting FAS Rates
The ingestion of alcohol whilst pregnant as well as personal risk factors (e.g. genetics, metabolism) affect the chances of a mother having a child with FAS [1] [2].
However, the causes behind FAS are not as simple as that.
Poole [3] states that a women's alcohol use is not just about alcohol. It is also about “stress, context, isolation, general health, age, genetics, resilience, cultural discrimination, exposure to violence, abuse, access to prenatal care, grief and loss, social policy and poverty”, all of which have a role to play in the development of FAS.
These factors, as a whole, are known as the ‘social determinants of health’ and outline the circumstances in which people live and work in and how they relate to health and illness. Social, economic and political factors all contribute to the likelihood of a child being born with FAS. Some of these factors are outlined below.
One social factor that affects the prevalence of FAS is culture. The social culture a woman grows up or lives in will affect, either subtly or directly, her behaviour and lifestyle choices she makes during pregnancy – including the choice to drink or not.
For example, in many populations a binge-drinking culture is prevalent. This normalises drinking large quantities of alcohol in relatively short periods of time, generally with the effect of drinking to become intoxicated. This type of drinking is particularly harmful to the fetus, with large amounts of alcohol consumption being linked with the most severe cases of FAS.
Cultures where binge-drinking is normalised also tend to have correspondingly high rates of FAS, as well as other alcohol-exposure related birth disorders.
One example of a binge-drinking culture includes the ‘coloured’ population in the Western Province of South Africa, with a long history of a binge drinking culture due to the historical ‘dop’ payment method [4] [5]. Closer to home, Australian FAS levels are highest in low socioeconomic groups and the Indigenous population, with the highest rates recorded in the Fitzroy Valley in Western Australia. Again, a binge drinking culture is common in these areas and it is not uncommon for women to continue to binge drink throughout pregnancy [8]. For more information on these groups see the post ‘Populations in danger – FAS rates worldwide’.
Culture is one social factor affecting the risk a woman has of having a child with FAS. However, other social determinants also affect FAS rates worldwide. Education – especially in regards to the effect of alcohol on the fetus – is integral in changing FAS rates.
Here are some statistics that outline the effect that education of the mother has on the chances of having a child with FAS.
47.3% of Australian women consumed alcohol while pregnant, before knowledge of their pregnancy [1]
19.5% continued to consume alcohol even after knowledge of their pregnancy [1]
30% intend to consume alcohol in a future pregnancy [1]
About one in ten Australians think it’s acceptable to drink in moderation whilst pregnant or breastfeeding [2]
Only 5% of Australians are familiar with the Guidelines on the risks from drinking alcohol [1]
So one in five women in Australia continue drinking even after they discover they are pregnant – this is a very worrying thought [1]. Women who do not know or understand the link between alcohol and FAS (or even what FAS or FASD is!) are considerably less likely to minimize their alcohol intake during pregnancy. A lack of education on the relationship between drinking and birth defects increases the chances a woman will drink whilst pregnant, and thus raises their chances of having a child with FAS.
Lower levels of education is also likely to act as a barrier for mothers to learn more about behaviours that affect their own health and the health of their child. A woman who is poorly literate is less likely to read and understand a book on fetal and maternal health compared to that of a highly literate woman.
As a result, populations with lower rates of education (in regards to both health literacy and overall education) have been correlated as having increased rates of FAS.
Although FAS occurs in all socioeconomic strata, FAS is more prevalent in lower socio-economic areas. This is generally due to increased alcohol intake – especially binge drinking – in lower socioeconomic populations.
Higher FAS rates in low SES groups may be due to a number of things. Lower socioeconomic groups generally have less access to education, especially higher education (mentioned previously). Low SES groups also often have diminished access to health care, decreasing the chances of a pregnant woman learning about behaviors that may harm the fetus. Compile these factors with a prevalent binge-drinking culture and you have the ingredients for rate so FAS higher than those of the rest of the population.
FAS and alcohol intake are further accentuated by the ‘negative cycle’ these two factors create. Women who drink alcohol whilst pregnant are more likely to have a child with FAS. FAS children are more likely to struggle at school compared to their fellow classmates, and often their incomes later in life reflect this. FAS-diagnosed individuals are also more likely to be incarcerated, engage in risky sexual behaviour and have drug and alcohol problems of their own. A drinking culture helps to normalise binge-drinking, a major risk factor for FAS. These factors then compound and may result in more females drinking whilst pregnant, which correlate to more children being born with FAS. And thus, the cycle continues.
In Australia, there are no mandatory warnings on alcohol products that outline the effects of alcohol consumption on the developing fetus. Any warnings you may see are purely at the discretion of the alcohol companies themselves. As mentioned previously, only 5% of Australian women know the alcohol guidelines for safe drinking [1]. A lack of knowledge of levels of alcohol safe for the fetus considerably affects a woman’s decision to drink whilst pregnant – mandatory labelling of alcohol should be a legal requirement.
At the moment, Australia taxes alcohol depending on the type of drink. For example, wines and traditional ciders are taxed at a percentage of their wholesale value (generally around 5%) whilst full strength draught beers sit at 30c per standard drink [6]. Flavoured ciders and alcopops are around 95c per standard drink [6]. There has been growing support in both Australia and Great Britain to tax alcohol as a set rate per standard drink [7]. This would mean the prices of the drinks of choice for binge drinkers, such as high strength products such as cask wine, would increase whilst other alcoholic beverages would remain similar or decrease. As alcohol price is the “most important single determinant of alcohol use and misuse," according to co-chair Professor Mike Daube (Curtin University) [7], it is hoped that a volumetric tax (set tax per standard drink) will help to curb binge drinking – and therefore, rates of FAS in the community.
As Poole [3] stated, a woman’s risk of having a child with FAS is dependant not only on her alcohol intake and personal factors, but also in the environment she finds herself in. Social, economic and political forces all interact to increase or decrease her chances of having a child with FAS. As a result, it is these social determinants of health that should also be addressed when considering combatting FAS in the wider community (see the ‘Prevention is better than cure’ post for more information on fighting FAS in the future!).
[1] Foundation for Alcohol research and Education (FARE), The Australian Fetal Alcohol Spectrum Disorder Action Plan. FARE - Foundation for Alcohol research and Education, Deakin , ACT [on-line]. Available From: http://www.fare.org.au/wp-content/uploads/2011/07/FARE-FASD-Plan.pdf [Accessed 5 April 2014].
[2] Williams F. One in three mums drink alcohol while pregnant or breastfeeding study. Herald Sun, 2010 [June 8) [on-line]. Available from: http://www.heraldsun.com.au/news/one-in-three-mums-drinks-alcohol-while-pregnant-or-breastfeeding-study/story-e6frf7jo-1225876678031 [Accessed 5 April 2014].
[3] Poole N. Mother and child reunion: preventing fetal alcohol spectrum disorder by promoting women's health. Vancouver, BC: BCCEWH; 2003.
[4] May PA, Gossage AP, Marais AS, Adnams CM, Hoyme HE, Jones KL, et al. The epidemiology of fetal alcohol syndrome and partial FAS in a South African community. Drug and Alcohol Dependence, 2007, Vol. 88(2–3), pp. 259–271.
[5] May PA, Tabachnick BG, Gossage JP, Kalberg WO, MaraisAS, Robinson LK, et al. Maternal risk factors predicting child physical characteristics and dysmorphology in fetal alcohol syndrome and partial fetal alcohol syndrome. Drug and Alcohol Dependence, 2011, Vol. 119(1–2), pp. 18–27.
[6] Cancer Council Victoria, Calls for Alcohol Tax Reform. Cancer Council, Victoria, April 2014 [on-line]. Available from: http://www.cancervic.org.au/about/media-releases/2012-media-releases/media-april-2012/alcohol-tax-budget.html [Accessed 10 April 2014].
[7] Hinde S & McKenna K, Calls for minimum alcohol price as alcopop tax fails to stop Australia’s young binge drinkers. The Sunday Mail, Queensland, January 2012 [on-line]. Available from: http://www.news.com.au/national/minimum-price-call-to-curb-binge-drinking/story-e6frfkvr-1226234132668 [Accessed 10 April 2014].
[8] Abel EL. An update on FAS: FAS is not an equal opportunity birth defect. Neurotoxicology and Teratology, 1995, 17, pp. 43.
