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This Article Extract Full Text (PDF) All Versions of this Article: AJPH.2004.057372v1 95/7/1099    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Rosenthal, J. Articles by Cordero, J. Search for Related Content PubMed PubMed Citation Articles by Rosenthal, J. Articles by Cordero, J. Related Collections Global Health Health Policy HIV/AIDS Pregnancy Alcohol

Jorge Rosenthal, PhD, Mc, Arnold Christianson, MD and Jose Cordero, MD

Jorge Rosenthal and Jose Cordero are with the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, Atlanta, Ga. Arnold Christianson is with the Division of Human Genetics National Health Laboratory Service and the University of the Witwatersrand, Johannesburg, South Africa.

Correspondence: Requests for reprints should be sent to Jorge Rosenthal, PhD, MC, National Center on Birth Defects and Developmental Disabilities, MS-E86, 1600 Clifton Rd, Atlanta, GA 30333 (e-mail: jyr4{at}cdc.gov).

	INTRODUCTION

TOP INTRODUCTION POLICYMAKERS HEALTH CARE PROVIDERS COMMUNITY WOMEN OF CHILDBEARING AGE CONCLUSIONS References

 
For decades, South Africa has endured an epidemic of fetal alcohol syndrome (FAS) that requires immediate and decisive public health attention. The prevalence rates of more than 40 cases per 1000 children in the Western and the Northern Cape Provinces and more than 20 cases per 1000 children in Gauteng Province represent some of the highest rates of FAS in the world.^1–3 May et al.’s article on maternal risk factors for FAS in South Africa⁴ should be a call to action to identify and apply strategies that can prevent this syndrome. It should also alert other low-resource nations in which alcohol is available and used by women of childbearing age to the possibility of a similar problem.

May et al. identify risk factors for FAS, such as binge drinking during pregnancy, maternal age, poor education, poor nutrition, genetic influences, gravidity, and poor socioeconomic environment, that provide a starting point for identifying women at risk and offering effective interventions. Not surprisingly, the risk factors found in South Africa are not much different from those found in high-income countries.⁴

Developing and implementing strategies to reduce alcohol use during pregnancy by targeting high-risk women may provide public health benefits beyond reducing the incidence of FAS if strategies for HIV and sexually transmitted diseases (STDs) can be integrated.^5,6 Bundled prevention efforts will benefit from efficiencies that can be brought into the delivery of primary health care and long-term costs of FAS to society.

May et al. suggest that prevention should be accomplished through social improvement and proven techniques of birth control, treatment for alcohol abuse, and screening for alcohol use during prenatal services. We agree that these are key prevention strategies that are directly informed by this study. However, additional public health efforts will be needed to achieve the expected outcome of reducing or eliminating FAS in South Africa and to sustain success. These efforts should include development of policies needed to address FAS nationwide, development of ongoing surveillance methods for FAS and alcohol use during pregnancy, training of health care professionals and community workers, and community education targeting high-risk women. Most important, prevention strategies should be addressed not only to women of childbearing age, but also to public health officials, policymakers, health care providers, and communities. Given the high rate of teenage pregnancies in South Africa, school children are particularly important targets in any effort to halt alcohol abuse by pregnant women.

	POLICYMAKERS

TOP INTRODUCTION POLICYMAKERS HEALTH CARE PROVIDERS COMMUNITY WOMEN OF CHILDBEARING AGE CONCLUSIONS References

 
As May et al. point out, FAS is a birth defect that results from exposure of the fetus to alcohol during pregnancy as well as a problem of substance abuse by the mother. As such it is primarily a maternal and child health (MCH) issue, one that has been recognized in the South African National Policy Guidelines for the Management and Prevention of Genetic Disorders, Birth Defects and Disabilities.⁷ Given the outreach to wide segments of the population that is possible through primary health care, MCH systems should contribute to FAS prevention. Given the common elements among the populations currently at risk for FAS, HIV, and STDs, such programs could maximize resources, efficiencies, and organizational synergies. The preconceptional, perinatal, and postnatal periods are obvious times for the concentration of efforts for prevention of FAS, HIV, and STDs. Outreach is required to draw more at-risk women into these services, as are efforts to highlight the specific needs of these women as part of maternal and child care. The national MCH program in South Africa should collaborate with the provincial programs to develop a national populationwide approach, through appropriate legislation and health policy, and an operational-level approach that integrates FAS, HIV, and STD prevention and control into MCH delivery services. Such integrated programs could stimulate broad support and would entail well-defined responsibilities, resources, and budgets.

FAS prevention requires a local, regional, and national surveillance system for FAS and for alcohol use during pregnancy. Researchers in South Africa have reported high FAS prevalence rates in some small communities in the Western Cape, Northern Cap, and Gauteng provinces. However, to assess the magnitude of FAS (local, regional, and national) requires an estimation of the prevalence of the disease and of the associated morbidity in the population as a whole, as well as the financial cost to individuals, families, and society. To accomplish such an estimate, we suggest that FAS, HIV, and STD programs develop integrated surveillance systems with similar data collection tools and engage in similar approaches for tracking and evaluation of prevention efforts.

	HEALTH CARE PROVIDERS

TOP INTRODUCTION POLICYMAKERS HEALTH CARE PROVIDERS COMMUNITY WOMEN OF CHILDBEARING AGE CONCLUSIONS References

 
Health care providers at all levels should be trained to screen for, diagnose, prevent, and treat an alcohol-exposed pregnancy. Curriculum programs and materials tailored to meet the learning needs of these professionals should be developed and used. This has, in part, been achieved in South Africa with the Perinatal Education Program’s Birth Defects Manual, which has been developed as part of a national genetic education program for primary care practitioners.⁸ However, like most health care workers’ curriculum materials, it does not comprehensively address risk-factor intervention techniques or long-term planning. These topics will need to be addressed at the national level.

Capacity-building of experienced staff to conduct training is essential. Their participation in the development of ideas for overcoming obstacles will assist them in offering effective, targeted health education. Training can incorporate role-playing to develop expertise in appropriate and effective health education and behavioral change techniques and strategies. Then, in communities in which FAS, HIV, and STDs are major health problems, screening and treatment for alcohol use and sexual behavior before and during pregnancy will allow providers to identify the at-risk population early. Interventions to influence sexual behavior and alcohol use can focus on education about risk reduction strategies and provision of the skills and means to negotiate and practice safe sex.

In low-resource countries like South Africa, capacity development will have to be achieved in an environment in which primary health care workers are already overburdened. The knowledge and skills imparted to them to address the problems associated with FAS (and HIV and STDs) will need to be succinctly packaged, of proven efficacy, and well marketed.

	COMMUNITY

TOP INTRODUCTION POLICYMAKERS HEALTH CARE PROVIDERS COMMUNITY WOMEN OF CHILDBEARING AGE CONCLUSIONS References

 
The social norms and policy environments governing communities affect the risks and protective behaviors of individuals. Interventions that address social network- and community-level phenomena have been effective in reducing HIV risk among a range of population groups in different geographic settings.⁹ Similar approaches can be implemented for FAS. For communities, changes in attitudes, norms, and practices can be brought about through health communication, social marketing, community mobilization and organization, and communitywide events. Interventions on community building and social support should enlist community leaders and other laypeople accepted by the community as reliable sources of information, including health workers, traditional leaders and healers, teachers, and representatives of the private sector implementing prevention and control programs.

	WOMEN OF CHILDBEARING AGE

TOP INTRODUCTION POLICYMAKERS HEALTH CARE PROVIDERS COMMUNITY WOMEN OF CHILDBEARING AGE CONCLUSIONS References

 
Women of childbearing age are the key element in successful FAS prevention. We need to better understand the many social and psychological processes that contribute to risky drinking and sexual activities in the environments in which these women live, and we must seek to delineate personal and societal interventions that are both acceptable and realizable.¹⁰

Individual- and group-level interventions should include education and counseling that promote safe sex behaviors, planned pregnancies, improved nutrition, and changes in alcohol consumption behavior. On the individual level, delaying pregnancy in the women at highest risk, including those who already have a child with FAS, is imperative. Education and support provided in group settings can promote and reinforce safer behaviors and are especially good for providing interpersonal skills training in negotiating and sustaining appropriate behavior change. Given the high rates of teenage pregnancy in South Africa, schoolchildren are a particularly important target in any effort to halt alcohol abuse by pregnant women.

	CONCLUSIONS

TOP INTRODUCTION POLICYMAKERS HEALTH CARE PROVIDERS COMMUNITY WOMEN OF CHILDBEARING AGE CONCLUSIONS References

 
We must continue to develop new methods of FAS prevention, remaining mindful of both the biomedical and the behavioral aspects of the problem. For example, prevention efforts that promote treatment for alcohol use and that incorporate safe-sex methods of protection will contribute to the prevention of FAS, HIV, and STDs in a way that women can control. If such efforts are successful in decreasing the prevalence of the target diseases, they can show communities that prevention efforts can work and therefore alter the perception that communities have about prevention.

Using the information that is becoming available, we need to develop new public health interventions for FAS prevention that are mindful of biomedical, behavioral, and social realities. These interventions must combine prevention of FAS, HIV, and STDs and must work on all levels of social organization, from individuals to whole societies. In pursuing the best practices and most effective interventions, we must recognize that these efforts will succeed at the level necessary to prevent FAS, HIV, and STD problems only if they are applied in combination and if fiscal and personnel resource are provided. Furthermore, they will succeed only if they are linked to other efforts to address the macro level social conditions that contribute to the disparate vulnerability of affected populations.

	Acknowledgments

 
We gratefully acknowledge Mary Mc-Cauley for her review of this editorial.

Accepted for publication October 24, 2004.

	References

TOP INTRODUCTION POLICYMAKERS HEALTH CARE PROVIDERS COMMUNITY WOMEN OF CHILDBEARING AGE CONCLUSIONS References

 
1. Control Centers for Disease and Prevention. Fetal alcohol syndrome—South Africa, 2001. MMWR Morb Mortal Wkly Rep. 2003;52(28):660–662.[Medline]

2. Control Centers for Disease and Prevention. Update: trends in fetal alcohol syndrome—Alaska, Arizona, Colorado and New York, 1995–1997. MMWR Morb Mortal Wkly Rep. 2002; 51:433–435.[Medline]

3. South African–US Consultation on Fetal Alcohol Syndrome Research: Scientific Progress and Future Directions. Summary. Cape Town: Government of South Africa and US Centers for Disease Control and Prevention; 2003.

4. May PA, Gossage JP, Brooke LE, et al. Maternal risk factors for fetal alcohol syndrome in the Western Cape Province of South Africa: a population-based study. Am J Public Health. 2005; 95:1190–1199.[Abstract/Free Full Text]

5. Askew I, Berer M. The contribution of sexual and reproductive health services to the fight against HIV/AIDS: a review. Reprod Health Matters. 2003; 11(22):51–73.[CrossRef][Web of Science][Medline]

6. Fetal Alcohol Syndrome: Guidelines for Referral and Diagnosis. Atlanta, Ga: Centers for Disease Control and Prevention; 2004.

7. National Policy Guidelines for the Management and Prevention of Genetic Disorders, Birth Defects and Disabilities. Pretoria, South Africa: South African National Department of Health; 2001.

8. Woods D. Birth Defects Manual. Cape Town, South Africa: Perinatal Education Trust; 2002.

9. AIDS Epidemic Update. Geneva, Switzerland: United Nations Programme on HIV/AIDS and the World Health Organization; December 1999.

10. Susser I, Stein Z. Culture, sexuality, and women’s agency in the prevention of HIV/AIDS in South Africa. Am J Public Health. 2000;90:1042–1048.[Abstract/Free Full Text]

This Article Extract Full Text (PDF) All Versions of this Article: AJPH.2004.057372v1 95/7/1099    most recent Submit a response View Shopping Cart Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Rosenthal, J. Articles by Cordero, J. Search for Related Content PubMed PubMed Citation Articles by Rosenthal, J. Articles by Cordero, J. Related Collections Global Health Health Policy HIV/AIDS Pregnancy Alcohol