A scoping review of the determinants of foetal alcohol spectrum disorder in South Africa: an intersectional perspective

Abstract

Foetal alcohol spectrum disorder (FASD) affects babies born to mothers who consume alcohol while pregnant. South Africa has the highest prevalence of FASD in the world. We review the social determinants underpinning FASD in South Africa and add critical insight from an intersectional feminist perspective. We undertook a scoping review, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews guidelines. Drawing from EBSCOhost and PubMed, 95 articles were screened, with 21 selected for analysis. We used the intersectionality wheel to conceptualize how the social and structural determinants of FASD identified by the literature are interconnected and indicative of broader inequalities shaping the women and children affected. Key intersecting social determinants that facilitate drinking during pregnancy among marginalized populations in South Africa documented in the existing literature include social norms and knowledge around drinking and drinking during pregnancy, alcohol addiction and biological dependence, gender-based violence, inadequate access to contraception and abortion services, trauma and mental health, and moralization and stigma. Most of the studies found were quantitative. From an intersectional perspective, there was limited analysis of how the determinants identified intersect with one another in ways that exacerbate inequalities and how they relate to the broader structural and systemic factors undermining healthy pregnancies. There was also little representation of pregnant women’s own perspectives or discussion about the power dynamics involved. While social determinants are noted in the literature on FASD in South Africa, much more is needed from an intersectionality lens to understand the perspectives of affected women, their social contexts and the nature of the power relations involved. A critical stance towards the victim/active agent dichotomy that often frames women who drink during pregnancy opens up space to understand the nuances needed to support the women involved while also illustrating the contextual barriers to drinking cessation that need to be addressed through holistic approaches.

Land Reform and Beyond in Times of Social–Ecological Change

“…Socioeconomic surveys conducted in the towns of Vanwyksvlei, Sutherland and Loeriesfontein between 2016 and 2019 found education and skill levels to be generally very low and the school dropout rate among teenagers alarmingly high (Walker & Vorster, in press). Respondents in all three towns identified alcohol and drug abuse and associated crime as major problemsas already noted, rates of alcoholism and foetal alcohol spectrum disorders are extremely high in this region (Olivier et al, 2016;De Jong et al, 2021). Worth noting is that these surveys did not find widespread interest in farming as a serious option, although some households expressed varying degrees of interest in accessing commonage land for grazing small herds, and a few individuals indicated an interest in land reform opportunities.…”

Influence of childhood trauma and traumatic stress on a woman's risk of having a child with a fetal alcohol spectrum disorder

“…Women facing often unbearable circumstances are left vulnerable to substance use as a means to cope or to forget (de Vries et al., 2016; Shrestha et al., 2018). Social relationships and norms strongly influence a women's relationship with alcohol (De Jong et al., 2021). A high level of social support has been shown to be protective against antepartum health risks including substance use (Racine et al., 2018).…”

“…Women are dependent on health services, the media, and the community to provide alcohol risk information in a way that is both accessible and understandable (Lyall et al., 2021). Stigma and discrimination are further barriers to treatment and support and may limit the effectiveness of such communication (Aspler et al., 2019; De Jong et al., 2021). Relationships between FASD, drinking behaviors, and historical and contemporary trauma have been reported in other countries with population groups of lower socio‐economic status, such as Australia and Canada (Fitzpatrick et al., 2015; Salmon, 2011).…”

Intersectionality as a theoretical framework for researching health inequities in chronic pain

“…27,47 Intersectionality has been conceptualised, and implemented, in different ways in literature reviews. De Jong et al 53 used intersectionality as a framework during a scoping review to develop analysis and policy recommendations for foetal alcohol spectrum disorder in South Africa, framing intersecting oppressions from downstream individual factors to upstream factors including the colonial context, racism and policy history. Husain et al 54 hoped to select studies that used intersectionality as a testable theory on the impact of marginalisation across intersecting categories of demographics with regards to digital care, but found that the studies used descriptive, rather than explanatory analysis.…”