Racialized Socioeconomic Status Effects on Fetal Alcohol Spectrum Disorder

Socio-economic inequalities exist in varying degrees throughout the United States. Many rural and inner-city areas are plagued with poverty, while many suburban areas are inhabited by middle and upper-middle class families. Changes in socioeconomic status (SES) are very closely tied with changes in access to food, housing, sanitation, and education, which have significant effects on overall physical and mental health. The effects of socioeconomic inequalities are exhibited not only in living conditions and health of living individuals, but in the reproduction of health and morbidity in future generations. Furthermore, SES is highly racialized in the United States, creating unique health circumstances for specific races and ethnicities in the US.

Fetal Alcohol Spectrum Disorder (FASD) refers to a diverse range of phenotypic abnormalities in child development as a result of toxicity build-up inside utero due to female alcohol consumption while pregnant. The effects of alcohol consumption while pregnant on the fetus range from craniofacial abnormalities associated with short palpebral fissures, thin vermillion border, and a smooth philtrum, along with CNS disorders, and growth deficiencies (Vorgias and Bernstein, 2019). The highly racialized hardships of low SES result in vulnerability of poor populations to have increased risk of having children born with FASD. The high rates of FASD in particular groups throughout the United States result in unnecessary social and economic hardships. These issues are perpetuated by a system of inequality that reproduces itself through healthcare inequalities rampant throughout the United States. Addressing these issues warrants need to address structural inequalities on an economic and social level.

FASD as a spectrum disorder ranges from mild, un-noticeable symptoms to severe, debilitating manifestations that may lead to death. Fetal Alcohol Syndrome refers to the more severe end of the spectrum, particularly to individuals who have central nervous system (CNS) disorders, distinct facial features (thin vermilion border and flat forehead), as well as growth problems. Furthermore, individuals who may not have all three criteria for FAS, may be characterized as having Alcohol-Related Neurodevelopmental Disorder (ARND) or Alcohol Related Birth Defects (ARBD), all of which are classified under FASD, according to the Center for Disease Control (CDC). Because of the wide range of case severity, FASD itself is not included in disability listings under Medicaid. Rather, individual symptoms that could include seizures, chronic heart failure, and mental disorders are used to determine social security eligibility. Although the individualistic symptom qualification system under Medicaid may help to account for comorbidity caused by FASD, it may fail to account for the less obvious symptoms that are more difficult to diagnose without highly trained professionals. Since those with low SES often don’t have access to specialized clinics, many fail to qualify for government assistance. The spectrum diagnosis of FASD poses just one difficulty among many for women of lower socioeconomic status who may not have access to highly trained doctors to identify less severe FASD cases.

In addition to difficulties accessing doctors to identify FASD in children, strong ties between the prevalence of FASD and SES have been observed in mothers who drink alcohol during pregnancy. Despite a 40% chance that a chronic alcoholic woman will bear a child with FAS, this figure varies heavily across socioeconomic statuses (Bingol et al., 1987). In a study conducted by six medical doctors who work with children with FAS, pregnant patients in substance abuse hospital units from upper and upper-middle class gave birth to children with FAS at a rate of 4.5%, while lower class mothers gave birth to children with FAS at a rate of 70.9% (Bingol et al., 1987). Additionally, this enormous difference in FAS diagnosis between SES appears regardless of drinking levels; there is a confounding factor most likely related to SES. Although women of high SES drink more heavily than women of lower SES, the children of women of lower SES suffer more severe FASD diagnosis and are more likely to be classified as having FAS (Pfinder et al., 2014; Pfinder et al., 2012; May and Gossage, 2011; McCormack et al., 2017).

Given the strong links between socioeconomic status and FASD regardless of drinking quantity, it has been theorized that links to comorbidity and nutrition care may play a large role in the effect alcohol has on the fetus. 89.6% of women of lower SES had a morbidity or comorbidity, compared to only 55.6% of women with higher SES. Furthermore, 100% of women with lower SES had at least one parent who was an alcoholic, while 36% of women of higher SES reported having at least one alcoholic parent, suggesting that many of the women with a lower SES may have had FASD themselves. FASD has been known to lead to chronic drinking in adolescents, leading to children of mothers with FASD to produce offspring with FASD (Bingol et al., 1987). This suggests that SES may play a large role in reproducing FASD generationally that is not linked to genetics.

Nutrition and access to particular types of food and alcohol may also play a role in FASD. Higher rates of FAS have been observed in women who consume beer while pregnant. In the 1987 study by Bingo et. al, it was noted that the drink of choice by pregnant women of lower SES was beer. This may largely be in part to beer being less expensive than other alcohol that women of higher SES reported drinking. Hence, there could be a link between SES and FASD that is in part due to types of alcohol consumed according to price availability.

It is important to point out trends within the relationship between FASD and SES. Due to the the close relationship between race and SES, higher proportions of cases of FASD and FAS are found in communities of color. In the 1987 study by Bingo et al. on the relationship between SES and FASD, it was reported that 100% of the women of high SES were white, while the lower SES group was 70.8% black women, 27% Hispanic women, and only 2% white women.Hence, the FAS diagnosis rate of 70.9% in the study were nearly all attributed to women of color. In the United States, only 0.3 per 10,000 children born to Asian Americans were diagnosed with FAS, the lowest rate in the country. Causasians have a rate of 0.8, while African Americans have a rate of 6.0 and Native Americans have a whopping rate of 29.9 cases per 10,000 births (Mangum et al., 2018). These trends reported also fall along SES lines, as Asian Americans have the highest annual income in the United States, while Native Americans have the lowest annual income. Even within the Native American population, tribes with greater economic development, such as the Navajo, report fewer cases of FAS (Mangum et al., 2018).

Systemic racism within the United States largely contributes to hierarchies in SES that mirror social climates towards groups of color. While SES is a very clear indicator of probability of FASD in pregnant women who drink, the race of the mother is often closely related to the SES of the mother. Furthermore, because women of higher SES, despite drinking more, have lower rates of FASD than women of lower SES, it is clear that other discrepancies in care, nutrition, and morbidity are likely the cause for high rates of FASD in children born to mothers of color and low SES. Racism alone experienced by mothers has been demonstrated to cause birth complications and less healthy babies (Dominguez et al., 2008); therefore, racism coupled with low SES may create a weaker neonatal environment, making alcohol more likely to severely impact the development of the child. The additional stress and physiological consequences of stress may lead to abnormal development due to racism. Furthermore, FASD can make it difficult for individuals to thrive in mental health, relationships, education, and work, leading to lower SES, which may lead them to have children with FASD as well. It is estimated that an individual with FAS pays around 1.4 million dollars in their lifetime for medical treatments (Stade et al, 2003). Given that many children with FAS are born into families of lower SES, the high medical costs further increase the likelihood of reproductive conditions of FASD. The reproduction of the FASD morbidity cycle is an indication of systemic racism in the United States. As a highly racialized cycle, FASD is one manifestation of how racism confounded with SES leads to physical and mental hardships for individuals and their families. It is important to remember that FASD is completely preventable. Therefore, in addition to education about FASD, steps to reduce economic inequalities as well as social inequalities may have substantial health benefits specifically for communities of color and their future health.

References

Bingol, N., Schuster, C., Fuchs, M., Iosub, S., Turner, G., Stone, R. K., & Gromisch, D. S. (1987). The influence of socioeconomic factors on the occurrence of fetal alcohol syndrome. Advances in alcohol & substance abuse, 6(4), 105-118.

Dominguez, T. P., Dunkel-Schetter, C., Glynn, L. M., Hobel, C., & Sandman, C. A. (2008). Racial differences in birth outcomes: the role of general, pregnancy, and racism stress. Health psychology, 27(2), 194.

Mangum, B. P. (2018). The social epidemiology and construction of risk for Fetal Alcohol Syndrome in Native American communities. Biostatistics and Epidemiology International Journal, 1(1), 25-29.

May, P. A., & Gossage, J. P. (2011). Maternal risk factors for fetal alcohol spectrum disorders: not as simple as it might seem. Alcohol Research & Health, 34(1), 15.

McCormack, C., Hutchinson, D., Burns, L., Wilson, J., Elliott, E., Allsop, S., ... & Mattick, R. (2017). Prenatal alcohol consumption between conception and recognition of pregnancy. Alcoholism: Clinical and Experimental Research, 41(2), 369-378.

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Pfinder, M., Liebig, S., & Feldmann, R. (2012). Explanation of social inequalities in hyperactivity/inattention in children with prenatal alcohol exposure. Klinische Pädiatrie, 224(05), 303-308.

Stade, B., Ungar, W. J., Stevens, B., Beyene, J., & Koren, G. (2006). The burden of prenatal exposure to alcohol: measurement of cost. J FAS Int, 4, e5.

Vorgias, D., & Bernstein, B. (2019). Fetal Alcohol Syndrome. In StatPearls [Internet]. StatPearls Publishing.