tag:theconversation.com,2011:/fr/topics/foetal-alcohol-spectrum-disorders-4889/articlesFoetal alcohol spectrum disorders – The Conversation2019-09-23T13:21:17Ztag:theconversation.com,2011:article/1236152019-09-23T13:21:17Z2019-09-23T13:21:17ZWhy alcohol remains a big threat to unborn babies in South Africa<figure><img src="https://images.theconversation.com/files/293545/original/file-20190923-54744-135rv1n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drinking during pregnancy is harmful and can lead to foetal alcohol spectrum disorders.</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Alcohol consumption is socially acceptable for individuals of legal drinking age. However, drinking during pregnancy is harmful and can lead to irreversible foetal cognitive and developmental issues. These are collectively known as foetal alcohol spectrum disorder. </p>
<p>The disorder may include foetal alcohol syndrome – the most serious of these abnormalities – as well as partial foetal alcohol syndrome. It can also include alcohol-related neuro-developmental disorders and birth defects. </p>
<p>Common risk factors associated with the disorder include low socioeconomic conditions, a low level of education, and harmful patterns of alcohol consumption. In South Africa, some alcohol abuse is believed to be rooted in a <a href="https://www.mdpi.com/1660-4601/11/7/7406">“dop” system</a>. This is a practice in which farmworkers’ wages were paid using alcohol beverages. Although this practice has been abolished, its lingering effects still influence South Africa’s drinking patterns.</p>
<p>South Africa has the <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2649225">highest</a> recorded prevalence of foetal alcohol spectrum disorder in the world. The prevalence rates range from <a href="http://www.samj.org.za/index.php/samj/article/view/11009">29 to 290 affected children per 1000</a> live births. The rates vary a lot across the country, with the Western Cape province recording the highest. Australia could be considered to have the second highest recorded prevalence in the world with <a href="https://www.ncbi.nlm.nih.gov/pubmed/28499185">194.4 affected children per 1000</a> among Australian Aboriginals.</p>
<p>The South African government’s policy responses to this problem have been inadequate. We conducted two pieces of research. In the <a href="https://rdcu.be/bReov">first</a>, we looked at a range of policy documents to identify clauses attributed to the prevention and management of the condition in South Africa. We supplemented this <a href="https://europepmc.org/articles/pmc6466131">with in-depth interviews</a> to help inform our recommendations.</p>
<p>We <a href="https://rdcu.be/bReov">discovered</a> that South Africa had introduced a host of new policy documents and there are a range of clauses in various guidelines. But the interventions are fragmented and don’t speak to one another. </p>
<p>Another problem is that most of the current prevention and management approaches are informed generic statements embedded in different policy documents. The association of foetal alcohol spectrum disorder with other genetic conditions ignores the socio-economic factors associated with it. This means a comprehensive approach to addressing foetal alcohol spectrum disorder doesn’t exist. </p>
<p>Our findings explain why the country has failed to make a dent in reducing the high rates. In our conclusions we recommend that the South African government should respond to the epidemic in a more coordinated and comprehensive way by designing a specific policy and targeted interventions.</p>
<h2>What we found</h2>
<p>The analysis we did indicated that 22 policy documents contained elements related to the condition. These included generic clauses focused on the regulation of liquor outlets, enforcement of liquor laws, and the general management of people with mental and educational challenges. </p>
<p>There were also clauses focused on creating platforms to improve the awareness, screening, identification and support for people with disabilities.</p>
<p>The in-depth <a href="https://europepmc.org/articles/pmc6466131">interviews</a> explored policymakers’ perspectives on policies and interventions for the prevention and management of foetal alcohol spectrum disorder. We spoke to policymakers from the departments of social development, health and education. The interviews included officials working on issues related the problem. </p>
<p>Our research contributes to the debate around the prevention and management of the disorder in South Africa. It highlights the need for policymakers to develop a specific policy and to address the fact that current interventions and services are uncoordinated and fragmented. </p>
<p>The development of a separate policy is not a panacea to address the problem. It would, nevertheless, be a good starting point as it would lay the basis for a comprehensive approach. And it would help to address the social drivers of foetal alcohol spectrum disorders. </p>
<h2>Policy considerations</h2>
<p>Current approaches have clearly not been effective. </p>
<p>The policymakers we spoke to expressed the need to develop a specific policy to address foetal alcohol spectrum disorder. But to be effective it should be multi-sectoral, family-centred and evidence-based. The policy should consider the needs of people with the disorder across their lifespan and their caregivers. It should also be clear about referral pathways and be based on a public health framework. </p>
<p>Such a policy should promote:</p>
<p>1) Awareness and education on the dangers of using alcohol during pregnancy in schools, clinics and communities.</p>
<p>2) The use of contraceptives and safe sex education to avoid unplanned pregnancies.</p>
<p>3) The training of service providers on how to counsel people with alcohol problems and diagnosis and management of foetal alcohol spectrum disorder.</p>
<p>4) The training and support of mothers and caregivers in the management of foetal alcohol spectrum disorder.</p>
<p>5) Skills training and empowerment programmes for people with the condition. </p>
<h2>Way forward?</h2>
<p>In the short term, the government can expand and link the clauses relating to foetal alcohol spectrum disorder that already exist in current policy documents. Existing services must be streamlined and current efforts to address the condition must be systematically evaluated to identify the gaps in services and interventions.</p>
<p>In the long term, South Africa needs to develop a separate policy for foetal alcohol spectrum disorder. This will facilitate the multi-sectoral collaborative approach needed to address the problem. Such an approach would go beyond managing the condition. Addressing foetal alcohol spectrum disorder would help the response to other societal problems. These include mental health problems, crime, intellectual disability and low levels of achievement in education.</p>
<p>The process of developing this policy must include a wide range of actors such as researchers, policymakers, service providers, people with the condition, their parents and caregivers. </p>
<p>We also argue that the South African government should replicate the success recorded in managing HIV and Aids. A <a href="https://sahivsoc.org/Files/ART%20Guidelines%2015052015.pdf">specific policy</a> was developed – based on goals set by the United Nations – that set a target known as <a href="https://theconversation.com/search/result?sg=1eb592ae-f39a-45cb-9713-b7961dc0f3de&sp=1&sr=1&url=%2Fhiv-aids-and-90-90-90-what-is-it-and-why-does-it-matter-62136">90–90–90</a>. The aim is that by 2020 90% of everyone with HIV must know their status, 90% of those diagnosed with HIV must receive antiretroviral therapy, and 90% of people receiving antiretroviral therapy must be virally suppressed.</p>
<p>In addition, the government should learn from approaches adopted by other countries like Australia and Canada, which developed action plans that led to an increase in government funding. The increased government funding led to the expansion of prevention programmes and the establishment of specialist diagnostic service.</p><img src="https://counter.theconversation.com/content/123615/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ferdinand C. Mukumbang receives funding from The South African Medical Research Council. </span></em></p><p class="fine-print"><em><span>Lizahn G. Cloete is the chairperson of the board of directors for FASfacts, a non-governmental organization that focuses on education and raising awareness for reduction and cessation of drinking during pregnancy. This organization does not, however, benefit directly from this article and were not involved in the conceptualization, initiation or implementation of this research or this article. </span></em></p><p class="fine-print"><em><span>Anna-Marie Beytell and Babatope O. Adebiyi do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There is no specific policy guiding the prevention and management of foetal alcohol spectrum disorder in South Africa.Babatope O. Adebiyi, Postdoctoral Researcher, University of the Western CapeAnna-Marie Beytell, Senior Lecturer, University of the Western CapeFerdinand C. Mukumbang, Researcher, University of the Western CapeLizahn G. Cloete, Senior lecturer, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1061292018-12-11T14:22:51Z2018-12-11T14:22:51ZThe problem of drinking in pregnancy – and what to do about it<figure><img src="https://images.theconversation.com/files/249941/original/file-20181211-76980-tvb0hp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The UK is believed to have one of the highest rates of Foetal Alcohol Syndrome in the world.</span> <span class="attribution"><span class="source">shutterstock</span></span></figcaption></figure><p>Last year, <a href="https://www.telegraph.co.uk/science/2017/01/19/four-10-british-mothers-drink-pregnancy-one-worst-rates-europe/">it was reported that the UK</a> has one of the worst rates of drinking while pregnant in Europe. These figures come from <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30021-9/fulltext">a study</a> which shows 41% of women in the UK drank alcohol during their pregnancy. Among UK women who drink any alcohol when pregnant, an estimated 19% drink <a href="https://www.sciencedirect.com/science/article/pii/S0890623817302824?via%3Dihub#sec0100">more than seven units of alcohol on one occasion</a>. This is defined as binge drinking.</p>
<p>Research has also found that the UK has one of the highest predicted prevalence of Foetal Alcohol Syndrome in the world. Foetal Alcohol Syndrome is the most severe form of <a href="http://adc.bmj.com/cgi/pmidlookup?view=long&pmid=18719155">Foetal Alcohol Spectrum Disorders</a>, a group of conditions that can occur in a person whose mother drank alcohol during pregnancy. </p>
<p>Foetal Alcohol Spectrum Disorders include a range of physical, mental, behavioural and learning disabilities. In the UK, 61 cases are estimated to occur for every 10,000 births. This is significantly higher that the global average of 15 out of 10,000 births. </p>
<p>These numbers however, do not give a picture of either timing or levels of alcohol exposure. <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/acer.13305">Australian research</a>, for example, shows that many women drink in the period before they know they are pregnant, but far fewer women continue when they find out they are pregnant. Similarly, <a href="https://beta.gov.scot/publications/scottish-maternal-infant-nutrition-survey-2017/pages/4/">a Scottish survey</a> reported that 12% of women drank after pregnancy confirmation – compared to 66% who drank before. </p>
<p>But of course, a limitation of these studies, as with any research study, is that they are restricted to individuals and may not be representative of the whole population.</p>
<h2>Mixed messages</h2>
<p>The fact then that a <a href="https://www.gov.uk/government/publications/health-profile-for-england-2018/chapter-4-health-of-children-in-the-early-years">recent report</a> by Public Health England on child health outcomes did not include alcohol as a contributing factor, seems very shortsighted. This is despite acknowledging that lifestyle factors are key determinants for child health in early years. </p>
<p>In the UK, there is no consistent system in place to monitor prevalence of alcohol use among pregnant women. Midwives ask about alcohol during the booking appointment, but it is not mandatory to record the information in a woman’s notes. Without confirmation of alcohol use during pregnancy, diagnosing Fetal Alcohol Spectrum Disorders and putting appropriate support in place, becomes much more difficult. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/249011/original/file-20181205-186085-1pv4p1h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/249011/original/file-20181205-186085-1pv4p1h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/249011/original/file-20181205-186085-1pv4p1h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/249011/original/file-20181205-186085-1pv4p1h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/249011/original/file-20181205-186085-1pv4p1h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=506&fit=crop&dpr=1 754w, https://images.theconversation.com/files/249011/original/file-20181205-186085-1pv4p1h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=506&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/249011/original/file-20181205-186085-1pv4p1h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=506&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Many women continue to drink while trying to conceive.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>The advice given to pregnant women in the UK about drinking alcohol during pregnancy has changed over time. In 2016, the Chief Medical Officers in the UK updated their <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/545937/UK_CMOs__report.pdf">guidelines</a> to recommend pregnant women abstain from alcohol. Previously the National Institute for Health and Care Excellence recommended women avoid alcohol, but limit their intake if they chose to drink. The reason for the change in recommendation was the uncertainty of whether drinking small amounts of alcohol is harmful. These guidelines align with many other countries, who also adopt the “precautionary principle”. </p>
<p>A study comparing experiences in England and Sweden showed both <a href="https://doi.org/10.1080/09687637.2018.1478949">midwives</a> and <a href="https://doi.org/10.1093/eurpub/ckx208">new parents</a> in England thought small amounts of alcohol might not harm the baby. In Sweden – where only one in ten women drink any alcohol during pregnancy – any alcohol was seen as risky, indicating that abstinence was generally accepted. </p>
<h2>Learning from others</h2>
<p>A new Fetal Alcohol Spectrum Disorders strategy has been published <a href="http://www.health.gov.au/internet/main/publishing.nsf/Content/55E4796388E9EDE5CA25808F00035035/$File/National%20Fetal%20Alcohol%20Spectrum%20Disorder%20Strategic%20Action%20Plan%202018-2028.pdf">in Australia</a> and
in Canada, a <a href="http://www.phac-aspc.gc.ca/hp-ps/dca-dea/prog-ini/fasd-etcaf/publications/cp-pc/pdf/cp-pc-eng.pdf">four-step prevention model</a> has been adopted by public health and research institutions. The Canadian model focuses on women making informed decisions and pregnancy planning to reduce the risk of harm. </p>
<p>Although not perfect, the model <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4861006/">has influenced prevention efforts</a> across all levels – from preconception to supporting new mothers. There is good evidence that information on alcohol and contraception to women of reproductive age can help to <a href="http://www.euro.who.int/en/publications/abstracts/prevention-of-harm-caused-by-alcohol-exposure-in-pregnancy.-rapid-review-and-case-studies-from-member-states-2016">prevent an alcohol-exposed pregnancy</a>. </p>
<p>Australia and New Zealand recently voted in favour of mandatory <a href="https://www.theguardian.com/australia-news/2018/oct/12/alcohol-labels-warning-of-risk-from-drinking-while-pregnant-will-save-lives">pregnancy warning on alcohol containers</a>. In Europe, it is compulsory for alcohol containers to carry warning labels in a handful of countries. There is no UK legislation on labelling, research shows that <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/add.13094">95% of products carry a warning</a> – most commonly a logo without text. Of course, warning labels aren’t a solution in themselves. Research shows that they can [stimulate conversations about alcohol] but we know less about how they <a href="http://www.ijadr.org/index.php/ijadr/article/view/126">affect behaviour</a>.</p>
<h2>Supportive alcohol policy</h2>
<p>Across the UK, there are positive developments in general alcohol policy – actions that will also have an impact of alcohol use during pregnancy. </p>
<p>This includes the introduction of a minimum unit pricing on alcohol in Scotland and the updated <a href="https://www.gov.scot/publications/alcohol-framework-2108-preventing-harm-next-steps-changing-relationship-alcohol/">Scottish Alcohol Framework </a>. The <a href="https://hansard.parliament.uk/Commons/2018-05-08/debates/54040204-9E54-4E2D-B9B0-21A9D4A24A2D/AlcoholMinimumUnitPricing#contribution-BA49A8DF-8F73-41AE-99E3-D5B4956E4297">UK government has also started the process</a> on a new alcohol strategy, but more still needs to be done.</p>
<p>Consistent, comparable data collection and prioritising women who consume alcohol during pregnancy is a first step forward for prevention, as is a coordinated approach for future alcohol policy. This will ensure the UK will not lag behind in addressing this important public health issue and that women, partners and children receive timely and appropriate support, where needed.</p><img src="https://counter.theconversation.com/content/106129/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa Scholin receives funding from the Institute for Alcohol Studies. </span></em></p><p class="fine-print"><em><span>Carolyn Blackburn is affiliated with the FASD UK Alliance who campaign for awareness about FASD and support for families.</span></em></p><p class="fine-print"><em><span>Lesley Smith receives funding from the Institute for Alcohol Studies.</span></em></p><p class="fine-print"><em><span>Moira Plant has in the past received funding from government and other bodies including the alcohol industry, the WHO and the Welcome Trust . </span></em></p><p class="fine-print"><em><span>Julie Watson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The UK is lagging behind the rest of the world when it comes to preventing harm caused by drinking during pregnancy.Lisa Schölin, Public health Research Fellow, The University of EdinburghCarolyn Blackburn, Reader in Interdisciplinary Practice and Research with Famililies, Birmingham City UniversityJulie Watson, Lecturer/Researcher, School of Health & Social Work, Faculty Health Science, University of HullLesley Smith, Professor of Women's Public Health, Institute of Clinical and Applied Health Research, University of HullMoira Plant, Emertus Professor of Alcohol Studies, University of the West of EnglandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1076492018-11-30T07:22:00Z2018-11-30T07:22:00ZUp to 17% of children in the UK could have symptoms of foetal alcohol spectrum disorder, according to latest estimates<figure><img src="https://images.theconversation.com/files/247951/original/file-20181129-170253-1x9q3q8.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/546641992?src=pJIgAofjXqfFvKVGKBjOpg-1-4&size=medium_jpg">GagliardiImages/Shutterstock</a></span></figcaption></figure><p>The UK has the <a href="https://www.thelancet.com/journals/langlo/article/PIIS2214-109X(17)30021-9/fulltext">fourth highest prevalence of drinking in pregnancy in the world</a>. This puts a significant number of people at risk of a group of conditions known as <a href="https://www.bma.org.uk/collective-voice/policy-and-research/public-and-population-health/alcohol/alcohol-and-pregnancy">foetal alcohol spectrum disorder</a> (FASD). Until now, though, the prevalence of FASD in the UK has not been known. </p>
<p>For our study, we followed the development of 13,495 children born in the west of England in the early 1990s. Using a wide range of information on their development and their mothers’ reported drinking in pregnancy, we developed a screening tool and found that <a href="https://doi.org/10.1016/j.ypmed.2018.10.013">up to 17% of children had features consistent with FASD</a>. </p>
<p>This means that these children had evidence of being exposed to alcohol in pregnancy and had problems with at least <a href="http://www.cmaj.ca/content/172/5_suppl/S1">three different areas of learning and behaviour</a>. Some children also had physical features of FASD, including below average growth and distinctive facial features (small eyes, smooth philtrum and a thin top lip). Most, however, did not show these physical signs. This suggests that FASD could be a relatively <a href="https://adc.bmj.com/content/93/9/721?utm_source=trendmd&utm_medium=cpc&utm_campaign=adc&utm_content=consumer&utm_term=0-A&casa_token=R7yHQi8L44MAAAAA:xPRdXbgTt-qRHVW-JDi3kWi7mQMcsy8b707IKVBE4GHT5Y6LbpJm008TROThTjWQfLjRtMo0HyTO">hidden disability</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/247754/original/file-20181128-32185-96jf9y.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/247754/original/file-20181128-32185-96jf9y.gif?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=346&fit=crop&dpr=1 600w, https://images.theconversation.com/files/247754/original/file-20181128-32185-96jf9y.gif?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=346&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/247754/original/file-20181128-32185-96jf9y.gif?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=346&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/247754/original/file-20181128-32185-96jf9y.gif?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=435&fit=crop&dpr=1 754w, https://images.theconversation.com/files/247754/original/file-20181128-32185-96jf9y.gif?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=435&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/247754/original/file-20181128-32185-96jf9y.gif?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=435&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/w/index.php?curid=5470170">NIH/National Institute on Alcohol Abuse and Alcoholism Public Domain</a></span>
</figcaption>
</figure>
<p><a href="https://doi.org/10.1016/j.ypmed.2018.10.013">Drinking in pregnancy was common</a> in the early 1990s. Up to 79% of mothers reported drinking alcohol in pregnancy, and a quarter of mothers reported binge drinking.</p>
<p>Information on drinking in pregnancy was collected in the early 1990s and guidance has since changed <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/545937/UK_CMOs__report.pdf">to recommend abstinence throughout pregnancy</a>. But rates of prenatal alcohol exposure in the UK have remained high. Recent estimates suggest that three-quarters of women drink during pregnancy, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26152324">with one third at binge levels</a>. This suggests that FASD is a problem that could affect many people in the UK today. </p>
<p>Consistent with our findings, international studies suggest that FASD is the <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2649225">leading cause of developmental disability worldwide</a>. Studies from <a href="https://jamanetwork.com/journals/jama/fullarticle/2671465">the US</a>, <a href="https://canfasd.ca/wp-content/uploads/sites/35/2018/08/Prevalence-1-Issue-Paper-FINAL.pdf">Canada</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/16930219">Italy</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/26423667">Poland</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/23591786">Croatia</a> estimate that 1-10% of school children are affected. In <a href="https://www.ncbi.nlm.nih.gov/pubmed/28498341">South Africa</a>, up to 28% of children could be affected. </p>
<h2>Overlooked health problem</h2>
<p>It is important to point out that the results of our study are based on a screening tool, which is <a href="https://www.healthknowledge.org.uk/public-health-textbook/disease-causation-diagnostic/2c-diagnosis-screening/screening-diagnostic-case-finding">not the same as a formal diagnosis</a>. Our results should be considered a starting point for understanding the potential scale of the problem in the UK, and more research on this poorly understood and complicated condition is needed. Still, the high rates of drinking in pregnancy and symptoms relevant to FASD that we found in our study suggest that FASD may be a significant and previously overlooked public health problem in the UK.</p>
<p>FASD is associated with <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)01345-8/fulltext">over 400 physical and mental health conditions</a>. The societal and economic costs associated with FASD are considerable, estimated to be <a href="https://www.ncbi.nlm.nih.gov/pubmed/26493100">CAN$1.8 billion per year in Canada</a>, and people with FASD are at
risk of other problems in later life, including <a href="https://journals.lww.com/jrnldbp/pages/articleviewer.aspx?year=2004&issue=08000&article=00002&type=abstract">alcohol and drug problems and trouble with the law</a>. Diagnosis and support can help reduce the risk of these problems in later life.</p>
<p>Our study is an important starting point because without UK estimates of FASD prevalence, awareness will remain low and those affected by this lifelong condition will continue to find it difficult to seek a diagnosis and access the support to help them achieve the best possible outcomes. </p>
<p>There are limited resources for FASD diagnosis and support in the UK, with <a href="https://www.fasdclinic.com">only one specialist clinic in England</a>. The <a href="https://publications.parliament.uk/pa/cm/cmallparty/180606/foetal-alcohol-spectrum-disorders.htm">All Party Parliamentary Group on FASD</a> and the <a href="https://www.bma.org.uk/collective-voice/policy-and-research/public-and-population-health/alcohol/alcohol-and-pregnancy">British Medical Association</a> concluded that research was urgently needed because until the true scale of the prevalence of FASD is understood, government and service commissioners will continue to have difficulty responding to the issue, including planning and providing appropriate levels of service. Our findings offer a starting point for addressing this research gap.</p><img src="https://counter.theconversation.com/content/107649/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cheryl McQuire does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Foetal alcohol syndrome disorder is a much under-recognised and unsupported condition in the UK.Cheryl McQuire, Research Associate in Epidemiology and Alcohol-Related Outcomes, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/566152016-04-07T05:35:06Z2016-04-07T05:35:06ZIndigenous youth with foetal alcohol spectrum disorder need Indigenous-run alternatives to prison<p>In recent weeks, the case of Rosie Anne Fulton, a young Northern Territory Indigenous woman with foetal alcohol spectrum disorder, has again attracted media attention. <a href="https://theconversation.com/what-making-a-murderer-tells-us-about-disability-and-disadvantage-in-criminal-law-53957">Rosie</a> was imprisoned for 21 months in Eastern Goldfields Regional Prison in Western Australia after being found unfit to stand trial on charges of reckless driving and motor vehicle theft. </p>
<p>Since her release in 2014, Rosie has been in and out of prison, without stable accommodation. Her guardian, former Territory police officer Ian McKinlay, says the lack of appropriate government support means Rosie will once again be “<a href="http://www.theguardian.com/australia-news/2016/mar/10/mentally-impaired-woman-roseanne-fulton-abandoned-by-government-again">abandoned to a perilous existence and imprisonment</a>”.</p>
<p>Rosie’s case highlights how the system is failing Indigenous people with foetal alcohol spectrum disorder.</p>
<p>Parliamentary committees have found Australia’s response to foetal alcohol spectrum disorder “lags <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/House_of_Representatives_Committees?url=spla/fasd/report.htm">behind other countries</a>” and that <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/House/Indigenous_Affairs/Alcohol/Report">there is</a> “a great need for diversion programs which redirect individuals who come in contact with the criminal justice system”.</p>
<p>To begin addressing the needs of Indigenous young people with foetal alcohol spectrum disorder, the criminal justice response must focus on diversion into Indigenous community-owned-and-managed structures and processes.</p>
<h2>What is foetal alcohol spectrum disorder?</h2>
<p>Foetal alcohol spectrum disorder is a non-diagnostic umbrella term encompassing a spectrum of disorders caused by prenatal alcohol exposure. That is, disorders a person may be born with if their mother consumed alcohol during pregnancy. The disorders on the spectrum range from mild to severe, and include diagnosis of foetal alcohol syndrome, partial foetal alcohol syndrome and alcohol-related birth defects.</p>
<p>People with foetal alcohol spectrum disorder may experience a range of cognitive, social and behavioural difficulties. This includes difficulties with memory and learning, impulse control and linking actions to consequences. All of these may render them more susceptible to contact with the criminal justice system.</p>
<h2>Foetal alcohol spectrum disorder and the criminal justice system</h2>
<p>The impairments associated with the disorder pose challenges at each stage of the criminal justice process. Difficulties with memory and suggestibility mean a person with foetal alcohol spectrum disorder is more likely to agree with propositions put to them and may therefore be disadvantaged in police interviews. </p>
<p>Difficulties with memory may make it harder for people with foetal alcohol spectrum disorder to explain their behaviour, to instruct lawyers and to give evidence in court. Difficulties with memory and linking actions to consequences may mean people are unable, rather than wilfully unwilling, to comply with court orders.</p>
<p>Research in the United States suggests <a href="http://journals.lww.com/jrnldbp/Abstract/2004/08000/Risk_Factors_for_Adverse_Life_Outcomes_in_Fetal.2.aspx">2%</a> of the population has foetal alcohol spectrum disorder and <a href="http://journals.lww.com/jrnldbp/Abstract/2004/08000/Risk_Factors_for_Adverse_Life_Outcomes_in_Fetal.2.aspx">60%</a> of persons with the disorder will be arrested, charged or convicted of a criminal offence. About half will have spent time in juvenile detention, prison, inpatient treatment or mental health detention. <a href="http://www.sciencedirect.com/science/article/pii/S0160252715001296">Canadian research</a> indicates young people with foetal alcohol spectrum disorder are 19 times more likely to be arrested than their peers.</p>
<p>While data in Australia is limited, <a href="http://bmjopen.bmj.com/content/2/3/e000968">estimates</a> of foetal alcohol syndrome in non-Indigenous populations range from 0.14 to 1.7 per 100 children, with rates in Indigenous communities indicatively higher. In 2015, rates of foetal alcohol syndrome/partial foetal alcohol syndrome of 12 per 100 children were <a href="http://bmjopen.bmj.com/content/2/3/e000968">reported</a> in Fitzroy Crossing in the West Kimberley region of Western Australia. This is the highest reported prevalence in Australia and on par with the highest rates internationally.</p>
<p>Awareness of the problem in Fitzroy Crossing has been driven by Aboriginal organisations, <a href="http://www.mwrc.com.au/">Marninwarntikura Womens Resource Centre</a> and <a href="http://nindilingarri.org.au/">Nindilingarri Cultural Health Services</a>, which already provide community-level support for families affected by foetal alcohol spectrum disorder. </p>
<h2>Secondary impairments</h2>
<p>An inadequate criminal justice response can also increase the likelihood of people with foetal alcohol spectrum disorder developing secondary impairments or disabilities, such as substance abuse. This, in turn, increases their susceptibility to contact with the criminal justice system (either as victims or offenders). This cycle is particularly concerning in the context of the worsening <a href="http://www.amnesty.org.au/images/uploads/aus/A_brighter_future_National_report.pdf">over-incarceration</a> of Indigenous youth in Western Australia.</p>
<p>Importantly, appropriate interventions can prevent or reduce secondary disabilities – by improving the responsiveness of the justice system and support services to young people with foetal alcohol spectrum disorder.</p>
<p>Improving diversionary pathways out of the criminal justice system might reduce the incidence of secondary impairments.</p>
<h2>Diversion</h2>
<p>Rather than prison, young people with foetal alcohol spectrum disorder need to be diverted into non-stigmatising therapeutic alternatives run by Indigenous people.</p>
<p>We call this a <a href="https://www.federationpress.com.au/bookstore/book.asp?isbn=9781760020576">“decolonising” approach</a> because the alternatives are Indigenous community-owned and managed. This approach acknowledges the strengths of Indigenous families and communities. The system may be “broken”; Indigenous Australia is not.</p>
<p>Our ongoing research with Indigenous stakeholders finds strong endorsement for an approach that places Indigenous organisations and Indigenous practices at the centre of intervention.</p>
<p>Much discussion of foetal alcohol spectrum disorder has, unsurprisingly, focused on the need for better screening and diagnostic services, as well as increasing the awareness of police and judicial officers.</p>
<p>Yet, there is also a need to build the capacity of communities and families to provide for the day-to-day care and support of young people with the disorder. Once a diagnosis has been presented, the main issue becomes how to <a href="http://sites.thomsonreuters.com.au/journals/files/2010/10/j05_v034_CRIMLJ_pt04_douglas_offprint.pdf">stabilise and support</a> the child. There is no medical “cure”. </p>
<p>There are examples of successful initiatives that could provide a basis for a new model of Indigenous youth justice. The <a href="http://www.yiriman.org.au/">Yiriman Project</a>, run by Cultural Bosses from around Fitzroy Crossing, takes young people at risk out onto traditional country, where they acquire bush skills in a culturally secure environment. </p>
<p>While there is no major evidence base suggesting that Indigenous-led diversion has better results than the mainstream, existing <a href="http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=60129545614">research</a> suggests Indigenous-led initiatives do have better outcomes in terms of reduced recidivism. A three-year <a href="http://www.aodknowledgecentre.net.au/aodkc/key-resources/aod-bibliography?page=15&q=&q_exact=&q_author=&as_values_tagged_keyword=&sorter=year-DESC&health_topic%5B%5D=19&year_start=1840&year_end=2016&lid=29786">review</a> of the Yiriman project found:</p>
<blockquote>
<p>Yiriman has assisted in the campaign to minimise young peopleʼs involvement in the justice system. Indeed, some, including a magistrate, conclude that Yiriman is more capable in this regard than most other diversionary and sentencing options.</p>
</blockquote>
<p>Indigenous organisations should be funded to provide mentoring and family support services, including “on-country” options that help to stabilise young people and heal families. </p>
<p>Indigenous communities want an opportunity to develop their own initiatives. It’s time we resourced a number of them and then evaluated them fully.</p><img src="https://counter.theconversation.com/content/56615/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tamara Tulich receives funding from the Australian Institute of Criminology through the Criminology Research Grants Program. The views expressed are the responsibility of the authors and are not necessarily those of the Australian Institute of Criminology.
</span></em></p><p class="fine-print"><em><span>Harry Blagg receives receives funding the Australian Institute of Criminology through the Criminology Research Grants Program. The views expressed are the responsibility of the authors and are not necessarily those of the Australian Institute of Criminology.</span></em></p>Rosie Anne Fulton, a young Northern Territory Indigenous woman with foetal alcohol spectrum disorder, highlights how the system is failing.Tamara Tulich, Lecturer, Law School, The University of Western AustraliaHarry Blagg, Professor of Criminology, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/351192014-12-05T14:16:10Z2014-12-05T14:16:10ZDrinking can harm a foetus, but court finds girl born with disorder wasn’t victim of crime<figure><img src="https://images.theconversation.com/files/66411/original/image-20141205-8642-exq2zy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A foetus is not 'a person', court rules. </span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic.mhtml?id=132280742&src=id">Scan by Shutterstock</a></span></figcaption></figure><p>A young girl born with Foetal Alcohol Spectrum Disorder is not entitled to criminal injuries compensation from her mother drinking excessively while pregnant, the Court of Appeal has decided. </p>
<p>It was alleged that the child (called “CP” in proceedings) was born with the disorder from her mother’s drinking, which included a half-bottle of vodka and eight cans of strong lager a day, in circumstances where the mother was aware of the danger of harm to her unborn child. As such, it was argued, the child should be entitled to compensation from the government-funded Criminal Injuries Compensation Authority (CICA) as an “innocent victim of crime”.</p>
<p>The story behind the case, brought on her behalf by the local authority funding her care, has stirred up considerable public and media debate and raises issues about the role of the criminal law and the burden of risk-taking behaviour during pregnancy. </p>
<h2>Compensation for criminal injury</h2>
<p>The rules under which the CICA administers the scheme were amended to exclude people with Foetal Alcohol Spectrum Disorder, but CP’s claim was considered under <a href="http://www.justice.gov.uk/downloads/victims-and-witnesses/cic-a/-information-if-you-applied-before-3-november-2008/cica-guide.pdf">an earlier 2008 version of the rules</a>. It was not disputed that CP had suffered injury. The central issue was whether she was a “victim of crime,” and if so, whether it was a crime of violence. There was also a further issue about whether the mother had the necessary “guilty mind” and whether this issue had been satisfactorily addressed by an earlier tribunal decision. </p>
<p>The mother was never prosecuted or convicted of a crime. However, CP alleged that her mother had committed a crime under section 23 of the <a href="http://www.legislation.gov.uk/ukpga/Vict/24-25/100/contents">Offences Against the Person Act 1861</a>; namely that she had unlawfully administered to “any other person any poison or other destructive or noxious thing” and as a result had inflicted grievous bodily harm. There was no dispute that the mother had administered the relevant “thing” as a result of her excessive alcohol consumption or that CP had sustained the necessary degree of harm – what was in issue was whether CP was “any other person.”</p>
<h2>The court’s decision</h2>
<p>The Court of Appeal determined that CP was not “any other person”. Applying <a href="http://www.publications.parliament.uk/pa/ld199798/ldjudgmt/jd970724/gneral01.htm">an earlier decision of the House of Lords</a> that had concluded that a foetus was not to be regarded as “another person” despite finding that it was a “separate organism from the mother”. </p>
<p>The court also ruled against CP’s alternative argument that equated her situation with the offence of manslaughter. This argument relied on the premise that a foetus becomes a person when it is born. The problem for CP was that the conduct element of the section 23 offence required the administration and the infliction of harm to be on “a person”. Infliction of harm on a foetus would not suffice. </p>
<p>Crucially, then, CP’s attempt to argue that some harm was caused after birth was also rejected: the foetal alcohol spectrum disorder was caused before her birth. Any post-birth suffering was regarded as a consequence of the harm suffered in the womb. As a result of these conclusions, the court did not find it necessary to reach any definite conclusion on the crime of violence issue. The court also accepted that the earlier tribunal had made sufficient findings and given sufficient reasons in relation to the mental element of the section 23 offence.</p>
<h2>Legal protection for the foetus</h2>
<p>Does this mean that the foetus has no protection under the criminal law in England and Wales? The court was keen to highlight the legal protection that was available. Sections 58 and 59 of the 1861 act provide criminal offences where there is an intention to kill the foetus prior to birth. So a mother who uses poison with intent to procure her own miscarriage is committing an offence. </p>
<p>Further, Section 1 of the <a href="http://www.legislation.gov.uk/ukpga/Geo5/19-20/34/section/1">Infant Life (Preservation) Act 1929</a> provides that it is an offence to destroy the life of a child capable of being born alive. Again the offender must have a certain guilty mind: intent to destroy the life. </p>
<p>A woman who drinks excessive alcohol during pregnancy may foresee risks to or for the unborn child as result of her conduct but foresight of some risk is not sufficient to show that she had the necessary “guilty mind” for these offences. It should also be highlighted that a doctor who complies with the requirements of the <a href="http://www.legislation.gov.uk/ukpga/1967/87/contents">Abortion Act 1967</a> does not commit these offences even if there is an intention to procure the miscarriage or death of the foetus.</p>
<p>The court also highlighted that a pregnant woman does not owe a civil duty of care to her unborn child and the child when born cannot bring a civil claim against her for harm caused during the pregnancy (except where the harm had been caused by her driving a motor vehicle). The court suggested that the law would be incoherent if a child was denied civil compensation but allowed criminal injuries compensation on the basis that her mother was criminally liable.</p>
<h2>The state of things</h2>
<p>Because CP’s claim was made by a local authority, it set up a situation where one organ of the state was claiming compensation against another. This raises a question about the role of the state in circumstances where conscious risk taking results in harm. Master of the rolls, Lord Dyson – the third most senior judge in England and Wales – made it clear <a href="http://www.judiciary.gov.uk/wp-content/uploads/2014/12/cp-cica.pdf">in his judgement</a> that:</p>
<blockquote>
<p>The role of the state in these circumstances should be to provide care and support for the child who has suffered harm to the extent that this is necessary. It should not be to pay compensation on the basis that the child is the victim of a crime by her mother.</p>
</blockquote>
<p>Much can be said about the awareness of the risks of excessive alcohol consumption during pregnancy and the extent to which these risks can be foreseen in circumstances like this case. However, it is legitimate to consider where and how the burden of conscious risk taking should fall in society. Given that a large number of similar claims for compensation by children allegedly harmed by alcohol in the womb were <a href="http://www.dailymail.co.uk/wires/pa/article-2860149/Ruling-womb-violence.html">reportedly awaiting the outcome</a> of CP’s appeal, this case makes clear, for now, that the criminal law (and the criminal injuries compensation scheme) is not the appropriate vehicle to address these issues.</p><img src="https://counter.theconversation.com/content/35119/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeffrey Wale does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A young girl born with Foetal Alcohol Spectrum Disorder is not entitled to criminal injuries compensation from her mother drinking excessively while pregnant, the Court of Appeal has decided. It was alleged…Jeffrey Wale, Lecturer in Law, Bournemouth UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/339102014-11-07T06:13:01Z2014-11-07T06:13:01ZGiving a foetus ‘personhood’ will have serious consequences for women<figure><img src="https://images.theconversation.com/files/63869/original/p83t5vx5-1415284298.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Not recommended. But criminal?</span> <span class="attribution"><span class="source">Lars Kristian Flem</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>A story of a woman who drank a half-bottle of vodka and eight cans of strong lager <a href="http://www.theguardian.com/law/2014/nov/05/foetal-damage-mother-alcohol-manslaughter">daily during pregnancy</a> and gave birth to a disabled child that ended up in foster care, was certain to stir up emotion and interest. Many will feel that “something must be done” to address behaviour that sounds unnatural, selfish and morally wrong. Based on what we know, <a href="http://www.bbc.com/news/health-29614413">heavy consumption of alcohol</a> is clearly not giving the foetus the best chance. Nevertheless, how we respond to such a situation is critical.</p>
<p>The case which has just been heard by the Court of Appeal brings the question of how we should respond keenly into view. Judges are considering their decision after a day-long hearing on a case brought by a local council seeking criminal injuries compensation on behalf of a six-year old child, “CP”, now in foster care.</p>
<p>CP was diagnosed at birth with <a href="http://www.fasdtrust.co.uk/">Foetal Alcohol Spectrum Disorder (FASD)</a> allegedly caused by her mother as a result of consuming excessive quantities of alcohol during pregnancy. The council claims, as was accepted by an initial tribunal, that this consumption of alcohol meant that the child had been a “victim of violence” by virtue of the mother having maliciously administered poison so as to endanger life or inflict grievous bodily harm as defined under <a href="http://www.legislation.gov.uk/ukpga/Vict/24-25/100/section/23">Section 23 of the Offences Against the Person Act 1861</a>. The upper tribunal, however, found that the child did not constitute a victim of violence because at the relevant time, the child was “not a person” in legal terms, but a foetus. As such, no crime had actually been committed to underpin a compensation claim. It is this decision that the Council appealed.</p>
<h2>All about compensation?</h2>
<p>At face value, the council’s objective looks pragmatic. The aim is not to encourage the prosecution or conviction of CP’s mother. It seeks an indemnity for costs incurred in providing for disabled children in its care. If successful, the “personal injury” it is claimed CP has suffered, of FASD (as opposed to <a href="https://www.drinkaware.co.uk/check-the-facts/health-effects-of-alcohol/fertility-and-pregnancy/foetal-alcohol-syndrome">Foetal Alcohol Syndrome</a>) could lead to many compensation claims, given that a significant proportion of children may have been removed from environments where parental neglect or abuse emerges as a result of substance abuse.</p>
<p>But to tap into the Criminal Injuries Compensation Scheme in the absence of an actual conviction, it needs to be determined whether a relevant crime has actually been committed. And this is why the case raises far broader issues than the health of the council’s finances. Though only involving a theoretical assessment that a crime has been committed, the ramifications for women will be very real, potentially inviting a whole host of legal measures with foetal protection at their heart.</p>
<p>Such fears are justified. In the United States, <a href="http://www.repository.law.indiana.edu/cgi/viewcontent.cgi?article=11110&context=ilj">many states now prosecute women</a> for committing criminal offences against their foetuses. Substance abuse by pregnant women has been a popular target with some States going to <a href="http://www.gwlr.org/wp-content/uploads/2012/08/76-6-Goodwin.pdf">extraordinary lengths to protect foetal life</a>. Some have passed legislation declaring the foetus to be a legal person, affording it a right to life from the moment of fertilisation. This makes applicable a wide range of offences, including that of child abuse or homicide that wouldn’t otherwise apply to the foetus. Short of recognising foetal personhood, some courts have <a href="http://www.advocatesforpregnantwomen.org/issues/whitner.htm">stretched child abuse laws</a> to include the foetus; in one case, a court prosecuted a woman under drug trafficking laws for passing drugs to her “child” during the 60-second gap between birth and cutting the umbilical cord.</p>
<h2>UK position</h2>
<p>Such approaches stand in stark contrast to English law where the foetus lacks legal personhood until born and holding a separate existence from its mother. The broad position is that a woman’s autonomy and right to bodily integrity trumps any interests a foetus might be said to possess. A pregnant woman can <a href="https://www.medico-legalsociety.org.uk/articles/protect_the_life.pdf">refuse medical treatment</a> even when this may result in the death of a viable foetus. The priority afforded to women’s interests is also reflected by the <a href="http://www.bbc.co.uk/news/health-19856314">Abortion Act 1967</a> which applies to England, Wales and Scotland; providing an abortion is performed in accordance with the 1967 Act, there is no offence.</p>
<p>It seems unlikely that the judiciary would risk unsettling a position so firmly embedded within English law, by suggesting that a woman could even theoretically have commissioned an act of violence against her foetus. Much is risked by so doing. Those most opposed to abortion and keen to limit women’s access to it, however, will see a successful appeal as a critical step in encouraging a legal regime which offers ever stronger foetal protection.</p>
<p>Nevertheless, the urge to extend the criminal law may emerge for completely different reason – those who see this as a truly exceptional and hard case demanding an exceptional response.</p>
<h2>Criminal law and extreme cases</h2>
<p>Hard cases, typically involving extreme situations, can generate powerful debate around our moral responsibility to prevent harm-causing behaviour – “something must be done!” The danger is that if not tempered by a full evaluation of broader concerns and a critical look at the criminal law as a vehicle for behavioural change, we can end up believing that criminalising conduct is justified.</p>
<p>The criminal law is a very blunt instrument. Even if we could be certain that the law would only be directed at those exceptional cases involving pregnant women engaging in heavy substance abuse (rather other kinds of risky activities), it’s unclear what benefits this could deliver, or for whom. The idea that criminal measures may be powerful in deterring women from engaging in such behaviour would seem to be founded upon some fallacy of choice and rational risk-benefit: that pregnant women who engage in such risky practices will weigh the risk of imprisonment and change their behaviour as a result.</p>
<p>More likely is that the threat of criminalisation will push those women who are most in need away from any help on offer for fear of criminalisation. As <a href="http://mli.sagepub.com/content/8/2/165.abstract">Emma Cave suggests</a>: “pregnant addicts would shun health care to avoid detection. It would constitute a step backwards’.</p>
<h2>Game of consequences</h2>
<p>A recognition of stronger foetal interests would have far-reaching consequences for women’s rights and bodily integrity and risk constructing all women as potential threats to foetal life.</p>
<p>So too would this sit at odds with abortion policy given the incoherence of criminalising women who it is alleged have caused serious or even lethal harm to their foetuses through alleged substance abuse or other "risky” practices, yet accepting as lawful the intentional demise of foetal life through abortion. When sat side-by-side it would create a perverse incentive for those engaged in risky behaviour to terminate.</p>
<p>Critically however, as US scholars have <a href="http://www.law.harvard.edu/students/orgs/crcl/vol39_2/bhargava.pdf">noted</a>, women are being punished in these cases for “risky” behaviour that would not, absent of pregnancy be subject to criminal punishment. As such, what makes substance abuse, alcohol consumption, even sex or attempted suicide the subject of the criminal law is not the behaviour itself, but the fact of pregnancy. Pregnant women – and indeed women – are being unfairly targeted.</p><img src="https://counter.theconversation.com/content/33910/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicky Priaulx does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A story of a woman who drank a half-bottle of vodka and eight cans of strong lager daily during pregnancy and gave birth to a disabled child that ended up in foster care, was certain to stir up emotion…Nicky Priaulx, Reader in Law, Cardiff UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/98132013-02-28T19:22:34Z2013-02-28T19:22:34ZAlcohol warning labels and ‘valuable label real estate’<figure><img src="https://images.theconversation.com/files/20741/original/rjyy64t5-1362013623.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The government’s discussions with the industry about voluntary labelling have not been transparent.</span> <span class="attribution"><span class="source">Jesús León</span></span></figcaption></figure><p>There’s a <a href="http://www.foodstandards.gov.au/foodstandards/userguides/labellingofalcoholic4967.cfm">legal requirement</a> in Australia for all packaged alcohol to show the alcohol content of the beverage and the number of standard drinks. But there’s no need for the label to bear any information about the <a href="http://www.nhmrc.gov.au/your-health/alcohol-guidelines/alcohol-and-health-australia">well-known health risks</a> of consuming alcohol. </p>
<p>The Commonwealth government is being urged to introduce warnings on alcoholic beverages. The alcohol industry says it’s not completely <a href="http://www.nhmrc.gov.au/your-health/alcohol-guidelines/alcohol-and-health-australia">opposed to labels</a>, but is determined to find ways to protect its “<a href="http://www.alsa.com.au/fileadmin/alsa-2009/Blewett_Review_FINAL.pdf">valuable label real estate</a>”. </p>
<h2>The case for alcohol warnings</h2>
<p>The Commonwealth government has received recommendations from its own advisory bodies that health information and warnings be mandated on alcoholic beverage containers, as part of a cohesive government strategy for reducing alcohol-related harm. </p>
<p>The first recommendation came from the <a href="http://www.preventativehealth.org.au/internet/preventativehealth/publishing.nsf/Content/CCD7323311E358BECA2575FD000859E1/$File/nphs-roadmap-5.pdf">National Preventative Health Taskforce</a> in 2009. The second (in 2011), came from the <a href="http://www.foodlabellingreview.gov.au/internet/foodlabelling/publishing.nsf/content/48c0548d80e715bcca257825001e5dc0/$file/labelling%20logic_2011.pdf">food labelling review</a>, which recommended specific warnings about drinking during pregnancy, and generic warnings about other health risks (such as alcohol is harmful to your health). </p>
<p>These calls for the Commonwealth to legislate for warnings on alcohol labels have been backed by the <a href="http://www.fare.org.au/wp-content/uploads/2011/07/AER-Policy-Paper_FINAL.pdf">Foundation for Alcohol Research and Education</a>, the <a href="http://ama.com.au/position-statement/alcohol-consumption-and-alcohol-related-harms-2012">Australian Medical Association</a> and the <a href="http://www.phaa.net.au/documents/101126Attachmenttosub-NAAAPositionStatement-Reducingharmfromalcohol-creatingahealthierAustralia.pdf">National Alliance for Action on Alcohol</a>. </p>
<p><a href="http://carbc.ca/Portals/0/PropertyAgent/558/Files/7/AlcWarningLabels.pdf">Several other countries</a>, such as the United States, South Korea and Brazil, require text-based warnings on alcohol containers. Studies of US labelling show evidence that alcohol warnings have effects on knowledge and attitudes about drinking, and “intervening variables”, such as intention to change drinking habits, willingness to discuss drinking, and being willing to intervene when seeing hazardous drinking in others.</p>
<p>There’s minimal evidence that warnings on alcoholic beverages change drinking behaviour. But if the labels are to impact behaviour, they need to be more graphic and visible than they have been in the past. Australia’s <a href="http://www.yourhealth.gov.au/internet/yourhealth/publishing.nsf/Content/tobacco-label-images">tobacco warnings</a> are an example of how successful product warnings can be.</p>
<h2>The Commonwealth’s response</h2>
<p>In December 2011, the Commonwealth government announced it was still considering whether to introduce generic warnings on alcohol, but that it was “prudent” to have warnings on alcohol about the specific risks from drinking during pregnancy. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/20745/original/y67fzzg6-1362014141.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/20745/original/y67fzzg6-1362014141.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/20745/original/y67fzzg6-1362014141.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/20745/original/y67fzzg6-1362014141.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/20745/original/y67fzzg6-1362014141.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/20745/original/y67fzzg6-1362014141.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/20745/original/y67fzzg6-1362014141.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It’s safest to not drink while pregnant.</span>
<span class="attribution"><span class="source">U.S. Department of Agriculture</span></span>
</figcaption>
</figure>
<p>The <a href="http://www.nhmrc.gov.au/your-health/alcohol-guidelines">National Health and Medical Research Council</a> guidelines state that for women who are pregnant or planning a pregnancy, it is safest not to drink when pregnant or planning a pregnancy. This reflects the concern about maternal alcohol consumption and <a href="https://theconversation.com/explainer-foetal-alcohol-spectrum-disorders-9871">foetal alcohol spectrum disorders</a>.</p>
<p>At this stage, the Commonwealth could have mandated a legal standard that alcoholic beverage containers bear pregnancy warnings in a prescribed format. Admittedly, this is not an entirely straight-forward process because of a treaty between Australia and New Zealand about joint food standards (including alcohol), and the sharing of food regulation powers between the Commonwealth and the states/territories. </p>
<p>Regardless, the government hasn’t mandated warnings. Instead, it has given the alcohol industry two years – until December 2013 – to introduce these warnings on a voluntary basis. And it seems that the government will only pass a labelling law if it’s not satisfied with what the industry has done by that deadline.</p>
<h2>Self-regulation is the wrong approach</h2>
<p>Alcohol labelling is not an appropriate matter for industry self-regulation. Foetal alcohol spectrum disorders are a serious public health issue that government has the responsibility and capacity to address. The alcohol industry has no special expertise in devising solutions to such problems. And it has a vested interest in limiting the size and impact of the warnings. </p>
<p>Allowing industry to self-regulate reduces both government and industry accountability. And it prevents a proper parliamentary debate about alcohol labelling that the public can participate in. </p>
<p>Indeed, the government’s discussions with the industry about voluntary labelling haven’t even been transparent. Has the government promised not to regulate if the industry does X or Y? And does it have any criteria by which it will judge whether the alcohol industry has done a good enough job at the end of 2013?</p>
<h2>The industry’s weak voluntary efforts</h2>
<p>The alcohol industry’s efforts to get pregnancy warnings onto alcohol containers are being lead by the industry-funded organisation, <a href="http://www.drinkwise.org.au/">DrinkWise</a>. Drinkwise recommends that that one of the following warnings be used on alcoholic beverages: </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/20736/original/hxkjkhq8-1362011522.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/20736/original/hxkjkhq8-1362011522.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/20736/original/hxkjkhq8-1362011522.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/20736/original/hxkjkhq8-1362011522.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/20736/original/hxkjkhq8-1362011522.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/20736/original/hxkjkhq8-1362011522.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/20736/original/hxkjkhq8-1362011522.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>There has been <a href="http://www.fare.org.au/wp-content/uploads/2011/07/IPSOS-SRI-DRINKWISE-AUDIT-REPORT-1-AUGUST-2012.pdf">poor take-up</a> of the DrinkWise pregnancy warnings. As at June 2012, only 4% of surveyed beers and ciders carried such a message, along with only 2% of wine, spirits and ready-to-drink products.</p>
<p>The industry is also not doing well at making the warnings visible or prominent. The same <a href="http://www.fare.org.au/wp-content/uploads/2011/07/IPSOS-SRI-DRINKWISE-AUDIT-REPORT-1-AUGUST-2012.pdf">recent survey</a> found that where the surveyed alcohol products bore a DrinkWise message, in 98% of cases, the message took up less than 5% of the alcohol label or packaging. It also found that labels were “on the margins …and rarely in central or prominent positions”.</p>
<p>The Commonwealth should not waste any more time on industry self-regulation of alcohol warnings. This government is generally too reticent in its regulation of the alcohol industry. In December 2013, it should act to mandate prominent, strongly-worded, graphic alcohol warning labels, and commission a proper study on the impact of those labels. </p>
<p><em>This is the ninth part of our series looking at alcohol and the drinking culture in Australia. Click on the links below to read the other articles:</em></p>
<p><strong>Part One:</strong> <a href="https://theconversation.com/a-brief-history-of-alcohol-consumption-in-australia-10580">A brief history of alcohol consumption in Australia</a></p>
<p><strong>Part Two:</strong> <a href="https://theconversation.com/social-acceptance-of-alcohol-allows-us-to-ignore-its-harms-10045">Social acceptance of alcohol allows us to ignore its harms</a></p>
<p><strong>Part Three:</strong> <a href="https://theconversation.com/my-drinking-your-problem-alcohol-hurts-non-drinkers-too-12424">My drinking, your problem: alcohol hurts non-drinkers too</a></p>
<p><strong>Part Four:</strong> <a href="https://theconversation.com/alcohol-fuelled-violence-on-the-rise-despite-falling-consumption-9892">Alcohol-fuelled violence on the rise despite falling consumption</a></p>
<p><strong>Part Five:</strong> <a href="https://theconversation.com/as-a-matter-of-fact-ive-got-it-now-alcohol-advertising-and-sport-9909">‘As a matter of fact, I’ve got it now’: alcohol advertising and sport</a></p>
<p><strong>Part Six:</strong> <a href="https://theconversation.com/advertisings-role-in-how-young-people-interact-with-alcohol-9986">Advertising’s role in how young people interact with alcohol</a></p>
<p><strong>Part Seven:</strong> <a href="https://theconversation.com/big-alcohol-and-big-tobacco-boozem-buddies-9668">Big Alcohol and Big Tobacco – boozem buddies?</a></p>
<p><strong>Part Eight:</strong> <a href="https://theconversation.com/explainer-foetal-alcohol-spectrum-disorders-9871">Explainer: foetal alcohol spectrum disorders</a></p>
<p><strong>Part Ten:</strong> <a href="https://theconversation.com/forbidden-fruit-are-children-tricked-into-wanting-alcohol-12457">Forbidden fruit: are children tricked into wanting alcohol?</a></p><img src="https://counter.theconversation.com/content/9813/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paula O'Brien does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>There’s a legal requirement in Australia for all packaged alcohol to show the alcohol content of the beverage and the number of standard drinks. But there’s no need for the label to bear any information…Paula O'Brien, Senior Lecturer in Faculty of Law, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/98712013-02-28T00:11:33Z2013-02-28T00:11:33ZExplainer: foetal alcohol spectrum disorders<figure><img src="https://images.theconversation.com/files/20732/original/mv7qq5ww-1362008424.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It's impossible to know how much alcohol is safe to consume during pregnancy.</span> <span class="attribution"><span class="source">Jason Coleman</span></span></figcaption></figure><p>The debate about alcohol’s harms is seemingly endless: the role of alcohol in violence, unplanned sex, injury and motor vehicle accidents, the teen binge-drinking epidemic, the risks of cancer and liver disease from chronic alcohol use and raising the legal age for purchase have all been discussed. Notably absent from the discussion is the effect of alcohol on the unborn child. </p>
<p>Foetal exposure to alcohol can have devastating consequences, impairing the subsequent growth, neurodevelopment, learning, and quality of life for the child.</p>
<h2>Alcohol is toxic to the foetal brain</h2>
<p>Alcohol is a teratogen, or toxin, that readily crosses the placenta. When a pregnant woman drinks, the foetus is bathed by blood containing alcohol, which can disrupt development of the brain, internal organs and face. </p>
<p>Foetal alcohol spectrum disorders encompasses a range of disorders that may result from alcohol exposure in the womb, including foetal alcohol syndrome, neurodevelopmental disorder associated with alcohol exposure, and a range of alcohol-related birth defects. </p>
<p>In north America, foetal alcohol spectrum disorders are the most common cause of developmental delay and <a href="http://www.fasdoutreach.ca/blog/admin/2011/10/dr-phillip-may-fasd-prevalence-rates">are said to affect</a> between 2% and 7% of all births. </p>
<p>Children with foetal alcohol spectrum disorders have <a href="http://pubs.niaaa.nih.gov/publications/arh40/118-126.htm">variable clinical features</a>. They may have a small or structurally abnormal brain, but even in the absence of such changes, they may have significant abnormalities of function, including problems with learning that limit their academic achievement. Ultimately, this <a href="http://www.ncbi.nlm.nih.gov/pubmed/17704098">affects their capacity</a> for employment and independent living. </p>
<p>Although the IQ range for such children is wide, they have particular problems with memory, executive function (planning and conduct of complex tasks), and numeracy. They often require remedial education, and frequently exhibit difficult behaviours (attention deficit hyperactivity disorder, conduct and oppositional disorders, risk-taking, anxiety and depression). They may have either solitary or overly-friendly personalities. </p>
<p>These children may grow poorly and have defects, and hence abnormal function, of the heart, kidneys, ears, eyes and other organs. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17704098">These problems</a> don’t go away. </p>
<p>Foetal alcohol spectrum <a href="http://www.ncbi.nlm.nih.gov/pubmed/12695315">disorders are lifelong</a> and as children enter adolescence, they are at higher risk than the general population of drug and alcohol dependence, anti-social and inappropriate sexual behaviours, mental health disorders, trouble with the law and incarceration. </p>
<p>But these disorders are preventable.</p>
<h2>Safe drinking and pregnancy</h2>
<p>People frequently ask how much alcohol is safe during pregnancy. Of course, this can never be answered based in human studies, and I think that it may, in fact, be irrelevant.</p>
<p>We know that women who drink no alcohol during pregnancy pose no risk to their foetus. And we know that frequent, high intake, particularly binge drinking, increases the risk. We also know that birth defects may result from first trimester alcohol exposure but that the brain is vulnerable to damage throughout the pregnancy. </p>
<p>And we know that risk to an individual pregnancy is impossible to predict because maternal (and hence foetal) blood alcohol levels are influenced by a range of factors including age, body composition, genetics and prior disease. So it’s better to apply the precautionary principle as recommended in Australia’s <a href="http://www.nhmrc.gov.au/your-health/alcohol-guidelines">national alcohol guidelines</a> – “for women who are pregnant or planning a pregnancy, not drinking alcohol is the safest option.” </p>
<p>Adding to this complexity is the high rate of unplanned pregnancy, estimated at around 50%, which suggests that inadvertent alcohol exposure may be common.</p>
<h2>Prevention is the only option</h2>
<p>Strategies to address foetal alcohol spectrum disorder have to focus on prevention. We need highlight the potential harms of alcohol use in pregnancy, as many women and their partners <a href="http://www.ncbi.nlm.nih.gov/pubmed/20727217">just don’t know</a> about it. This will involve public education strategies, including labelling of alcoholic beverages. </p>
<p>But labelling will only effectively improve knowledge if mandated and enforced, not left to the alcohol industry. Labels must be legible, prominent, and informative. </p>
<p>A recent survey by the <a href="http://www.fare.org.au/">Foundation for Alcohol Research and Education</a> (FARE) has <a href="http://www.fare.org.au/research-development/community-polling/annual-alcohol-poll-2012/awareness-of-standard-drinks-and-the-guidelines/">showed that</a>, under the current voluntary code, only 16% of alcoholic beverages were labelled and many of these were unreadable or simply referred to a website.</p>
<p>And this brings me back to the debate about alcohol raging in our community. Preventing foetal alcohol spectrum disorder, like all other alcohol-related harms, requires <a href="http://www.ncbi.nlm.nih.gov/pubmed/21781309">attitudinal and behavioural change</a>. Prohibition is not the solution and behavioural change must be supported by interventions with proven efficacy. </p>
<p><em>This is the eighth part of our series looking at alcohol and the drinking culture in Australia. Click on the links below to read the other articles:</em></p>
<p><strong>Part One:</strong> <a href="https://theconversation.com/a-brief-history-of-alcohol-consumption-in-australia-10580">A brief history of alcohol consumption in Australia</a></p>
<p><strong>Part Two:</strong> <a href="https://theconversation.com/social-acceptance-of-alcohol-allows-us-to-ignore-its-harms-10045">Social acceptance of alcohol allows us to ignore its harms</a></p>
<p><strong>Part Three:</strong> <a href="https://theconversation.com/my-drinking-your-problem-alcohol-hurts-non-drinkers-too-12424">My drinking, your problem: alcohol hurts non-drinkers too</a></p>
<p><strong>Part Four:</strong> <a href="https://theconversation.com/alcohol-fuelled-violence-on-the-rise-despite-falling-consumption-9892">Alcohol-fuelled violence on the rise despite falling consumption</a></p>
<p><strong>Part Five:</strong> <a href="https://theconversation.com/as-a-matter-of-fact-ive-got-it-now-alcohol-advertising-and-sport-9909">‘As a matter of fact, I’ve got it now’: alcohol advertising and sport</a></p>
<p><strong>Part Six:</strong> <a href="https://theconversation.com/advertisings-role-in-how-young-people-interact-with-alcohol-9986">Advertising’s role in how young people interact with alcohol</a></p>
<p><strong>Part Seven:</strong> <a href="https://theconversation.com/big-alcohol-and-big-tobacco-boozem-buddies-9668">Big Alcohol and Big Tobacco – boozem buddies?</a></p>
<p><strong>Part Nine:</strong> <a href="https://theconversation.com/alcohol-warning-labels-and-valuable-label-real-estate-9813">‘Valuable label real estate’ and alcohol warning labels</a></p>
<p><strong>Part Ten:</strong> <a href="https://theconversation.com/forbidden-fruit-are-children-tricked-into-wanting-alcohol-12457">Forbidden fruit: are children tricked into wanting alcohol?</a></p><img src="https://counter.theconversation.com/content/9871/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Elliott does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The debate about alcohol’s harms is seemingly endless: the role of alcohol in violence, unplanned sex, injury and motor vehicle accidents, the teen binge-drinking epidemic, the risks of cancer and liver…Elizabeth Elliott, Professor of Paediatrics & Child Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.