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Objective: Determine the prevalence of Dop, a system of labor payment via alcoholic beverages, in a South African province, and its influence on maternal drinking and fetal alcohol spectrum disorders (FASD). Methods: Data from studies of FASD epidemiology were analyzed. Results: Forty-two percent to 67% of mothers reported drinking. In 1999, 5% of women reported Dop allocations in their lifetime: 14% of mothers of FASD children and 1% of controls. In 2010, 1.1% of mothers reported lifetime Dop: 1.6% of FASD mothers and 0.7% of controls. Commercial alcohol sales have replaced the Dop system. Total FASD rates remained high in rural areas in 2010 and rose in urban settings. Urban rates of total FASD surpassed rural area rates in 2010. Correlation analysis did not reveal a strong or significant, direct relationship between Dop experience and heavy drinking (r = 0.123, p < 0.001, r2 = 0.015), or the diagnosis of FASD in children (OR = 0.003, p = 0.183). Conclusion: Dop, as a systematic practice, is dead and does not have a direct influence on alcohol availability, heavy maternal drinking, or the probability of an FASD diagnosis. Nevertheless, today’s problematic drinking patterns were heavily influenced (shaped) by Dop and have negatively impacted the prevalence and severity of FASD.
Data for this exploration originated from seven different population-based samples, collected between 1997 and 2011, to define the prevalence and detailed characteristics of FASD in a general population sample in the WCP. These studies were active case ascertainment (ACA) studies of FASD clinical cases found among children in community public schools. Interviews were also conducted, in person, with the mothers of the study children [11,12,13,14,15,21,22,23,26,27,28]. The studies were carried out in two regional community settings of the WCP. Community A is a town of 35,000 people and surrounded by rural areas, with 15,000 people located about a one-hour drive by automobile from Cape Town. Community B is a large, separate region, located across a mountain range from Community A and located two to three hours of driving from Cape Town. Contained within Community B, there are four smaller towns and very large surrounding rural areas of vineyards and farms, with a total population approaching 65,000 people. A three-tier system was used to screen and provide diagnoses for all children in first-grade classes in community schools who had consented to participate in the study through their parents. In Tier I, all consenting children were screened for height, weight, and head circumference, and a large random sample was chosen from all enrolled first-grade children. Every consenting child that was ≤25 centile on head circumference and/or whose height and weight participated in Tiers I and II, along with all randomly-selected children who had been selected from all enrolled children from the same classes and schools, regardless of Tier I pre-screening and size, were included. In Tier II, complete growth, development, and dysmorphology examinations were provided to the above children, both those that were small and randomly-selected [29,30]. Then, for Tier III, all randomly-selected children and those small children who were found to have physical traits characteristic of prenatal alcohol exposure and possible FASD underwent a battery of neurobehavioral tests assessing intelligence, cognitive functioning, behavior, and life skills. Additionally, in Tier III, the mothers of all study children were informed of our interest in identifying maternal risk factors for all FASD births, and those who consented to the maternal interview were interviewed about a variety of maternal risk factors. There were many detailed questions about alcohol consumption during the index pregnancy and in their lifetime, and the questions about alcohol access from a variety of sources, including their experience with the Dop system, were embedded in the maternal questionnaire. The questionnaire utilized a time-line-follow-back sequence, along with questions concerning diet, childbearing history and experience, residence, general health, and socioeconomic status. Diagnoses of the children were made according to the first revision of the U.S. Institute of Medicine (IOM) Guidelines [29]. The IOM diagnostic system was used among first-grade students in all of the samples in which the data were generated. Classification of children was based on a full consideration of the following: (1) physical growth and dysmorphology; (2) cognitive/behavioral assessments; and (3) maternal alcohol consumption. Furthermore, other known genetic and teratogenic anomalies were ruled out before a FASD diagnosis was made. Final diagnoses were made for each child in a formal, data-driven, case conference per updated guidelines and operational criteria, as suggested by the IOM committee [29]. The entire IOM continuum of FASD diagnoses is represented by four diagnoses: fetal alcohol syndrome (FAS), partial fetal alcohol syndrome (PFAS), alcohol-related neurodevelopmental deficits (ARND), and alcohol-related birth defects (ARBD) [29,31]. For FAS, a child must have a characteristic pattern of minor facial anomalies; evidence of prenatal and/or postnatal growth retardation; evidence of deficient brain growth; and if possible, confirmation of maternal alcohol consumption. For PFAS, a child must have evidence of a characteristic pattern of facial anomalies and one or more other characteristics (small head circumference and/or evidence of a complex pattern of behavioral or cognitive abnormalities, and direct or collateral confirmation of maternal alcohol consumption). For ARND, a child must have documentation of significant prenatal alcohol exposure; display neurological or structural brain abnormalities; or manifest evidence of a complex and characteristic pattern of behavioral or cognitive abnormalities not explained by genetic predisposition, family background, or environment alone. For ARBD, a child must have confirmed prenatal alcohol exposure and evidence of the characteristic pattern of facial anomalies, as well as either major malformations or a pattern or minor malformations, but a generally normal neurobehavioral performance [29]. The occurrence of ARBD is quite rare. For most of the analyses in this manuscript, all four of the specific diagnoses in the continuum of FASD are grouped together and treated as one category, denoted the total FASD. Data analysis was performed using SPSS, Version 26 [32], for all analyses in this paper: for descriptive data and statistical tests presented in the tables and figures, for the calculation of partial correlations, and for sequential regression analysis.
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