'Every time he struggles with his school work I blame myself as a mother," says Geraldine Niemand*, fiddling uncomfortably with the armband on her wrist and shaking her head in regret. She stares out of the window at a group of children playing on the lawn.
"I might have damaged my child while I was having a good time by drinking when I was pregnant."
Like many other women Bhekisisa spoke to in the small, forlorn town of De Aar in the Northern Cape, Niemand frequently drank alcohol while pregnant.
"None of us thought that drinking during pregnancy was a big deal," she says. "We didn't realise the kind of damage we were causing to our unborn babies."
Babies born to mothers who drink while pregnant are at risk of developing fetal alcohol spectrum disorders, a collective name used to describe the irreversible birth defects caused by maternal consumption of alcohol.
Damage caused to babies exposed to alcohol before birth includes behavioural and learning difficulties, so that such children struggle to shift focus from one task, such as playing outside during their break, to another, such as sitting still in a classroom.
Lian-Marie Drotsky, who heads the Foundation for Alcohol Related Research in De Aar, says these children might find it hard to make sense of the lessons they are taught and end up dropping out of school.
No amount is safe
It is uncertain exactly how much alcohol a pregnant woman can consume before irreversible damage is done to her unborn baby.
According to the Medical Research Council, regular binge drinking – heavy, occasional, drinking of five or more units of alcohol at a time – can have devastating effects on the fetus.
"No amount of alcohol is safe during pregnancy. Even light to moderate drinking can harm your baby," says Drotsky.
Fetal alcohol syndrome is the most severe effect of maternal alcohol consumption; the condition can, according to the Nutrition Information Centre at Stellenbosch University, lead to mental disabilities and the deformation of other organ systems.
The centre says that fetal alcohol syndrome is the most common preventable cause of delayed development in babies and young children worldwide.
"Binge drinking during pregnancy can lead to delayed growth, brain damage and low weight at birth in babies," says Drotsky. "Physical features of children with fetal alcohol syndrome include small, wide-set eyes, a smooth upper lip and small, low-set ears. But it all depends on which stage of the pregnancy the mother was drinking and how much alcohol she was consuming."
Northern and Western Cape hardest hit
A study by the Cape Town-based Foundation for Alcohol Related Research between 2001 and 2003 showed that 12.2% – more than one in 10 – of grade one pupils in De Aar have fetal alcohol syndrome – the highest reported rate in the world.
In 2013 the foundation estimated that two million babies are born with fetal alcohol syndrome in South Africa every year, and six million more children and adults in South Africa are likely to have fetal alcohol spectrum disorders.
Although babies in urban areas are also affected by the condition, the foundation says, infants in rural areas in the Western Cape and towns in the Northern Cape are the hardest hit.
A study published in the South African Medical Journal last year said that fetal alcohol spectrum disorders (of which fetal alcohol syndrome is the worst) "are endemic in impoverished communities of the Western Cape and Northern Cape".
In the past 10 years some areas have recorded prevalence rates of fetal alcohol spectrum disorders as high as 208 in 1 000 babies in parts of the Western Cape.
More than 20% of pregnant women in the Western Cape admit to binge drinking. According to the study, the rate is so high because "heavy drinking has been socially entrenched and normalised" in these communities.
The Foundation for Alcohol Related Research programme in De Aar focuses on early intervention by informing pregnant women about the risks of drinking alcohol during pregnancy.
The organisation works with about 140 pregnant women every year. About 40 of these are considered high-risk and may give birth to a baby affected by fetal alcohol spectrum disorder if there is no intervention.
According to Drotsky, the prevalence of fetal alcohol syndrome in De Aar dropped from 122 in 1 000 babies in the early 2000s, when the organisation first started working in the area, to 86 in 1 000 in 2009.
The overall fetal alcohol syndrome prevalence rate in South Africa is not available as studies have only been conducted in the Northern Cape and Western Cape and in some Gauteng communities.
However, the numbers that are known are much higher than levels recorded in, for example, the United States, where prevalence rates ranked between 0.33 and 2.2 in 1 000 babies.
Drotsky says intervention such as that by the Foundation for Alcohol Related Research will not have an effect unless the communities's economic and social circumstances are addressed.
She says it is difficult for women in De Aar to stop drinking when they are pregnant because the culture of alcohol is entrenched in the community.
"There aren't a lot of options in terms of recreation in De Aar. The people here often feel hopeless. Unfortunately, some parents use their childcare grants to buy alcohol. Poverty is rife, but you can get very drunk on little money here," says Drotsky.
For example, she says, a jug of homebrewed beer costs as little as 50c.
"Most people know the risks of drinking during pregnancy such as alcohol dependency. But people think that it won't happen to them."
Niemand says that it wasn't hard for her to stop drinking once she realised how much danger she had put her children in.
The foundation's fieldworkers recruited her during an antenatal visit to the clinic eight weeks into her last pregnancy. Niemand says she was still drinking at that point.
"We always thought it was a myth when people said, 'Don't drink when you're pregnant; don't smoke during pregnancy'. But here [at the Foundation for Alcohol Related Research] I got first-hand knowledge of what [fetal] alcohol syndrome is.
"It is here that I learned what alcohol really does to your unborn baby or to your baby who is being breast-fed," says Niemand, stretching out in the beige couch in the sparsely furnished room in the Foundation for Alcohol Related Research's Joan Wertheim Centre, where she and many other mothers in De Aar reached a turning point.
The mother of five says she is ridden by guilt because she drank during all of her previous pregnancies.
"When the foundation for alcohol-related research started working here we had heard about alcohol syndrome but we didn't really know what it was because we hadn't really faced it directly or experienced it ourselves, so we just carried on [drinking] – just as people are carrying on now."
Niemand believes all of her children are healthy. But her eldest son frequently struggles at school, and she wonders if drinking during her pregnancy with him could be the cause.
"I am happy with my children's health so far, even though you don't really know how much harm has been done unless you can physically see it.
"If they have it [fetal alcohol syndrome], then it hasn't been picked up yet. But I'm concerned about my eldest son."
*Not her real name
Lenadine Koza, from the Medical Research Council, was a fellow with Bhekisisa from September to October 2013.
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In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.