摘要：Objectives. We defined risk factors for fetal alcohol syndrome (FAS) in a region with the highest documented prevalence of FAS in the world. Methods. We compared mothers of 53 first-grade students with FAS (cases) with 116 randomly selected mothers of first-grade students without FAS (controls). Results. Differences between case and control mothers in our study population existed regarding socioeconomic status, religiosity, education, gravidity, parity, and marital status. Mothers of children with FAS came from alcohol-abusing families in which heavy drinking was almost universal; control mothers drank little to no alcohol. Current and past alcohol use by case mothers was characterized by heavy binge drinking on weekends, with no reduction of use during pregnancy in 87% of the mothers. Twenty percent of control mothers drank during pregnancy, a rate that declined to 12.7% by the third trimester. The percentage who smoked during pregnancy was higher for case mothers than for control mothers (75.5% vs 30.3%), but the number of cigarettes smoked was low among case mothers. The incidence of FAS in offspring of relatively young women (28 years) was not explained by early drinking onset or years of drinking (mean, 7.6 years among case mothers). In addition to traditional FAS risk factors, case mothers were smaller in height, weight, head circumference, and body mass index, all anthropomorphic measures that indicate poor nutrition and second-generation fetal alcohol exposure. Conclusions. Preventive interventions are needed to address maternal risk factors for FAS. The search for specific maternal risk factors for fetal alcohol syndrome (FAS) has been ongoing for more than 2 decades via prenatal clinic 1 – 6 and epidemiological studies. 7 – 10 Population-based research is particularly helpful in identifying traits of the very highest-risk mothers—those who have borne children with full-blown FAS—and in designing prevention strategies. 10 – 14 FAS has been associated with heavy, episodic (binge) drinking that produces high blood alcohol concentration (BAC); advanced maternal age; high gravidity and parity; unstable marital status; cigarette use; and use of other drugs. 5 , 15 – 18 In the United States, higher FAS rates are reported among Black and American Indian women, low–socioeconomic status (SES) groups, people with high scores on various alcohol abuse assessment tools, and women with alcoholic male partners. 19 – 24 Studies of mothers of children with fetal alcohol spectrum disorder (FASD; referred to by the Institute of Medicine 18 as FAS, partial FAS, alcohol-related birth defects, and alcohol-related neurodevelopmental deficits) point to a dose–response effect. The probability of anomalies such as microcephaly, craniofacial defects, and behavioral problems depends on the level of alcohol exposure as modified by certain maternal characteristics, such as those on which this article reports. 5 , 25 – 28 The rate of FAS in US children is 0.05 to 2.0 per 1000 births. 29 All levels of FASD affect, at minimum, 1% of the birth population. 30 The highest rates of FAS in the world have been reported in the Republic of South Africa. The rate of full-blown FAS alone has been reported to be 46 cases per 1000 births in the Western Cape Province. 8 Current research is documenting even higher rates in Western Cape Province 31 and high rates elsewhere in South Africa. 32 FAS is associated with low SES among sub-populations 23 , 33 in developed and developing countries. 9 , 34 In South Africa, 8 , 35 mothers of children with FAS were of lower SES than were control mothers. In 1 US study that compared women of differing SES who consumed 12 drinks daily, the rate of FAS was 45 times greater in women of low SES than in women of middle and upper SES. 34 In the United States, England, and Canada, 20%–32% of pregnant women drink, and in some European countries the rate is higher, exceeding 50%. 13 – 18 , 36 – 39 In the Western Cape Province, 34% of urban women and 46%–51% of rural women drink during pregnancy. 40 , 41 Maternal drinking during pregnancy varies among and within populations throughout the world. 33 That alcohol abuse and FAS cluster in families implies both social and genetic influences in susceptibility. 10 , 42 – 44 Some alcohol-abusing families appear to escape many symptoms of FASD. 7 , 33 , 45 Families with 1 or more children with FASD experience serious physical and mental problems that pose a challenge to all types of service providers. 46 Because maternal risk for FASD involves an interaction of biological, familial, historical, social, and psychological factors, 46 research and prevention foci are interdisciplinary. 14 In the general literature on alcohol abuse, maternal risk factors for FASD include smoking; abusing drugs; cohabiting with an alcoholic male partner; sexual dysfunction; having alcohol-abusing parents; initiating drinking at an early age; and having low self-efficacy, poor life goals, and few interests. 3 , 19 , 48 – 55 Protective factors identified as providing strong normative or cultural support for abstinence or light drinking include high education; religiosity; and unique social, psychological, biological, and genetic traits. 9 , 35 , 56 – 58 Nevertheless, many risk factors for FASD are not well understood, and their explication is vital for prevention efforts. 14 , 59 , 60 Background of the Region We describe a study 9 of maternal risk for FASD in a town and its rural areas (population = 45 225; 22% of the area is rural) in the Western Cape Province of South Africa. Most inhabitants are “Colored,” defined as racially mixed individuals of African, European, and Asian descent. The town is similar to many others in this agricultural and wine-producing region. Heavy, episodic drinking has been the norm among laborers for generations. For several centuries, alcohol was provided daily to farmworkers as partial payment for work, a system known as the “dop” system, after the Afrikaans word for drink. Though this system of payment was formally outlawed by multiple statutes years ago, its effects persist. Local people who are forced to tolerate low pay, limited opportunity, and humble living conditions value alcohol as a favored commodity. Frequent binge drinking, defined as 3 or more drinks per episode of drinking, is common. South Africa researchers have documented high levels of alcohol abuse among male workers of the region. 61 – 64 Although no formal dop system survives, drinking heavily in groups on weekends and holidays remains a common form of recreation. Commercially produced beer and wine are cheap, readily available, and consumed by a population that, although poor, can allocate enough money to obtain and consume substantial quantities over short periods of time. This pattern results in high BAC values, placing fetuses at risk for FASD. 65 – 69 We refer to this pattern as the “dop legacy.” Maternal drinking was identified as a serious health problem in Western Cape Province in the mid-1990s. 70 , 71 Research confirmed high rates of FAS. 8 , 9 , 72 We describe risk factors for FAS to improve FAS prevention efforts in this and similar communities.
