High global prevalence of alcohol use during pregnancy and fetal alcohol syndrome indicates need for urgent action

In The Lancet Global Health, Svetlana Popova and colleagues1Popova S Lange S Probst C Gmel G Rehm J Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysis.Lancet Glob Health. 2017; (published online Jan 12.)http://dx.doi.org/10.1016/S2214-109X(17)30021-9Summary Full Text Full Text PDF PubMed Scopus (429) Google Scholar report unacceptably high global prevalence rates of alcohol use in pregnancy (9·8%) and fetal alcohol syndrome (FAS) (14·6 cases per 10 000 population) and estimate that each year 119 000 children are born with FAS. This finding is tragic because FAS is a leading cause of intellectual disability, birth defects, and developmental disorders, yet is entirely preventable.2Senturias YS Fetal alcohol spectrum disorders: an overview for pediatric and adolescent care providers.Curr Probl Pediatr Adolesc Health Care. 2014; 44: 74-81Crossref PubMed Scopus (16) Google Scholar FAS is a lifelong condition which might also result in secondary disabilities including academic failure, substance misuse, mental ill-health, and contact with the law due to illegal behaviours, with huge resultant costs to our health, education, and justice sectors.3Popova S Lange S Burd L Rehm J The economic burden of fetal alcohol spectrum disorder in Canada in 2013.Alcohol Alcohol. 2016; 51: 367-375Crossref PubMed Scopus (74) Google Scholar, 4Popova S Lange S Bekmuradov D Mihic A Rehm J Fetal alcohol spectrum disorder prevalence estimates in correctional systems: a systematic literature review.Can J Public Health. 2011; 102: 336-340Crossref PubMed Google Scholar Previous studies provide regional and national estimates of prevalence of alcohol use in pregnancy5O'Keeffe LM Kearney PM McCarthy FP et al.Prevalence and predictors of alcohol use during pregnancy: findings from international multicentre cohort studies.BMJ Open. 2015; 5: e006323Crossref Scopus (89) Google Scholar, 6Chambers CD Yevtushok L Zymak-Zakutnya N et al.Prevalence and predictors of maternal alcohol consumption in 2 regions of Ukraine.Alcohol Clin Exp Res. 2014; 38: 1012-1019Crossref PubMed Scopus (39) Google Scholar and FAS.7Roozen S Peters GJ Kok G Townend D Nijhuis J Curfs L Worldwide prevalence of fetal alcohol spectrum disorders: a systematic literature review including meta-analysis.Alcohol Clin Exp Res. 2016; 40: 18-32Crossref PubMed Scopus (203) Google Scholar One strength of the paper by Popova and colleagues is the use of a country-specific, random-effects meta-analysis to estimate prevalence by WHO region of alcohol use in pregnancy (0·2% in the Eastern Mediterranean Region to 25·2% in the European Region) and FAS (0·2 cases per 10 000 general population in the Eastern Mediterranean to 37·4 per 10 000 in the European region), and to provide the first estimates of global prevalence. Furthermore, Popova and colleagues link indicators of alcohol use in pregnancy and FAS to calculate that one in every 67 women who consume alcohol during pregnancy will have a child with FAS. The literature search was systematic, the meta-analysis carefully done, and the authors used country-specific variables in models to estimate alcohol consumption. Limitations of the Article relate to limitations of the data in the included primary studies. Few of these studies provided prevalence data that were truly population-based or national; only 16·5% of researchers used a validated method to identify the level of risk from prenatal alcohol exposure (PAE); and analysis of patterns of PAE were considered beyond the scope of the review. Timing, dose, and frequency of PAE are all important when considering the risk of FAS.8O'Leary CM Nassar N Zubrick SR Kurinczuk JJ Stanley F Bower C Evidence of a complex association between dose, pattern and timing of prenatal alcohol exposure and child behaviour problems.Addiction. 2010; 105: 74-86Crossref PubMed Scopus (80) Google Scholar We support the use of standardised, validated methods to obtain such information when asking women about their alcohol use in pregnancy.9Muggli E O'Leary C Donath S et al.“Did you ever drink more?” A detailed description of pregnant women's drinking patterns.BMC Public Health. 2016; 16: 683Crossref PubMed Scopus (68) Google Scholar Future analysis of PAE patterns might give insights to assist clinicians in providing evidence-based advice to women and in understanding groups most at risk of having a child with FAS. Accurate identification of FAS prevalence is challenging because of the global use of several different diagnostic criteria; different methods of case ascertainment; low confidence of health professionals making the diagnosis; and little access to normative data (eg, for assessment of sentinel facial features or neurodevelopmental impairment) for many specific ethnic populations.10Burns L Breen C Bower C O'Leary C Elliott EJ Counting fetal alcohol spectrum disorder in Australia: the evidence and the challenges.Drug Alcohol Rev. 2013; 32: 461-467PubMed Google Scholar Because of restricted availability of primary data, this Article only provides prevalence estimates for FAS. FAS is characterised by severe neurodevelopmental impairment and distinctive facial dysmorphology; however, in addition to FAS, PAE could cause a spectrum of disorders, including neurodevelopmental impairment without facial features.2Senturias YS Fetal alcohol spectrum disorders: an overview for pediatric and adolescent care providers.Curr Probl Pediatr Adolesc Health Care. 2014; 44: 74-81Crossref PubMed Scopus (16) Google Scholar Although FAS is the most easily recognised condition in the spectrum, it represents only the tip of the iceberg of the adverse effects of PAE, and hence the global prevalence reported here is just part of the story. Data from special populations (eg, Indigenous women, adolescents, women with low socioeconomic status, women with HIV, and women with an alcohol use disorder) were deemed not to be generalisable to the general population of their respective countries, and hence were excluded from the analyses. This approach emphasises the important public health message that alcohol use in pregnancy and FAS are not restricted to disadvantaged groups, but occur throughout society, regardless of socioeconomic status, education, or ethnicity. However, because high prevalence is reported in many of the excluded studies,11Fitzpatrick JP Latimer J Carter M et al.Prevalence of fetal alcohol syndrome in a population-based sample of children living in remote Australia: the Lililwan project.J Paediatr Child Health. 2015; 51: 450-457Crossref PubMed Scopus (72) Google Scholar estimates of regional and global prevalence might be conservative. We congratulate Popova and colleagues on this study. The key messages are striking and require an immediate response. Of every 10 000 people in the general population globally, 15 will have FAS, yet FAS is completely preventable. At least 10% of women in the general global population, and up to 25% in Europe, continue to expose their unborn babies to alcohol. Preventing PAE requires an understanding of why women drink. A Swedish study12Skagerström J Häggström-Nordin E Alehagen S The voice of non-pregnant women on alcohol consumption during pregnancy: a focus group study among women in Sweden.BMC Public Health. 2015; 15: 1193Crossref PubMed Scopus (6) Google Scholar using focus groups with young, non-pregnant, non-parous women to explore their attitudes towards alcohol consumption during pregnancy, found most women were aware of the potential for harm to the unborn baby. However, women articulated societal factors (eg, peer pressure, not wanting others to suspect they were pregnant), insufficient education (eg, some thought drinking small amounts during pregnancy was harmless), and personal factors (eg, not wanting to miss enjoyment of alcohol) as reasons that they felt would make abstinence during pregnancy difficult.12Skagerström J Häggström-Nordin E Alehagen S The voice of non-pregnant women on alcohol consumption during pregnancy: a focus group study among women in Sweden.BMC Public Health. 2015; 15: 1193Crossref PubMed Scopus (6) Google Scholar We must support families currently living with FAS. However, there is also an urgent global need for evidence-based initiatives to prevent FAS.13Jonsson E Salmon A Warren KR The international charter on prevention of fetal alcohol spectrum disorder.Lancet Glob Health. 2014; 2: e135-e137Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar Education, awareness-raising, training of health professionals, and brief interventions for women are crucial, but to drive attitudinal change in society these must be underpinned by measures to restrict access to and harms from alcohol, including appropriate pricing, taxation, restrictions on density and opening times of liquor outlets, and restriction on advertising and promotion of alcohol.14Elliott EJ Fetal alcohol spectrum disorders in Australia—the future is prevention.Public Health Res Pract. 2015; 25: e2521504Google Scholar TWT is supported by a grant from the National Health and Medical Research Council (NHMRC) of Australia Centre of Research Excellence (#1110341), of which EJE is Co-Director. EJE is supported by an NHMRC Practitioner Fellowship (#1021480). The Australian Paediatric Surveillance Unit is supported by the Australian Government Department of Health. We declare no competing interests. Estimation of national, regional, and global prevalence of alcohol use during pregnancy and fetal alcohol syndrome: a systematic review and meta-analysisAlcohol use during pregnancy is common in many countries and as such, FAS is a relatively prevalent alcohol-related birth defect. More effective prevention strategies targeting alcohol use during pregnancy and surveillance of FAS are urgently needed. Full-Text PDF Open Access

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