In a dusty township in South Africa’s sun-drenched wine country, Charay Afrika says only one thing helped numb her through a turbulent relationship and two pregnancies: alcohol.

She drank all day, every day, throughout her full-term pregnancies – unaware of the effect alcohol could have on her children.

Afrika was still at school when she met her first boyfriend, a man who would go on to beat her and rob her at gunpoint multiple times before she finally escaped him. “He’d beat me and lock me in the house with no food and then disappear for days,” Afrika, 28, says quietly. “I once had to drug him with sleeping pills so that I could call the neighbours and beg for help to sneak out. But he found me again and robbed me at gunpoint, and the whole thing started all over again. I drank as a way of escaping it all. I drank the whole time. I didn’t stop.”

Now eight years old and at school in Roodewal township, her eldest child has learning difficulties and behavioural problems – telltale signs of foetal alcohol syndrome (FAS), a condition under the broader umbrella of foetal alcohol spectrum disorder (FASD), which can manifest in birth defects such as brain damage, physical and mental impairments and stunted growth. It is directly caused by the mother’s drinking during pregnancy.

FAS affects more children in South Africa than anywhere else in the world: prevalent in 111 per 1,000 children, a rate 14 times higher than the global average of 7.7 per 1,000, according to the American Medical Association journal JAMA Pediatrics. But even this estimate may be lower than the true figure, say social workers in the Western Cape, as FAS is often a “hidden disability” that can affect a child in a number of ways, not all immediately obvious to parents or doctors.

“It’s a development issue,” says Sudene Jeftha, a social worker with FASfacts, an NGO based in Worcester. “You can’t necessarily see it when the child is born, only later when the child isn’t talking or crawling or walking like other children.”

The condition is endemic in the Western and Northern Cape, where high levels of unemployment, alcohol and substance abuse and teen pregnancies are intrinsic to daily life. In high-risk rural areas, up to 72% of school-age children are believed to suffer from FAS. Experts point to the 200-year-old dop system, in which Afrikaner farmers pay black and mixed-race workers in wine, or dop, as the primary cause of the regions’ high prevalence of alcoholism. Although the system was outlawed long ago, as many as 20% of vineyards are estimated to still pay their workers in wine, and binge-drinking in the Western Cape is a major health concern.

There is no concerted national health effort to tackle the issue, nor have there been any government studies to measure the socioeconomic impacts. But in a country where as many as six million people are thought to be affected by FASD and an additional three million are thought to have had foetal alcohol exposure, comparisons with other nations come in handy. In the UK, research has shown that it costs £2.9m to raise a child with FAS across their lifespan, while a Canadian study found that FAS youths were 19 times more likely to end up in jail than their peers.

Facebook Twitter Pinterest A shebeen, or illegal tavern, in Gugulethu, a troubled township outside Cape Town. Photograph: Rodger Bosch/AFP/Getty Images

A number of NGOs, including FASfacts, now run courses in at-risk communities to spread awareness of the condition, as well as “mentor mother” programmes, which rely on local mothers going door-to-door to speak to pregnant women about drinking. FASfacts, founded in 2002 by François Grobbelaar (an Afrikaner whose father used to pay his farmworkers in dop), claims this approach has helped reduce the number of pregnant women who drink by as much as 84%.

Veronic Blom, 33, drank and used tik (crystal meth) throughout her first two pregnancies. She was approached by one of FASfacts’ mentor mothers and stopped using both during her third pregnancy. Blom is now a mentor mother herself. “I smoked heavily – heavily – for the whole nine months of the pregnancy,” she says of her second child, now aged two. Making a rectangle with her thumb and forefinger, she indicates the size of a full gram of meth. “I’d smoke the full packet and smoke the whole day. I can only thank God he wasn’t born with any problems with his face.”

From the corrugated-iron shack in the Esselen Park township she shares with her two youngest children, Blom says the programme has changed her for the better. “I’m very talkative and I like to give back and speak to other mothers,” she says. “I usually tell them my own story so they know they don’t have to use their stories as an excuse: they can do better. The women are mostly keen to do better, but teenage pregnancy here is very common, you know, women selling their bodies to buy drugs or food.”

Just a few miles away, in Roodewal, another mentor mother, Flori Koetaan, 52, gestures outside, where an armoured police van is rumbling down the dusty roads. “Half the time this is a no-go zone,” she says of the constant gang warfare. “They set fire to the houses and have shootouts. Sometimes ambulances can’t even enter because they try to hijack the drugs inside. My first [mentoring] client was a pregnant 45-year-old mother whose 15-year-old daughter was also pregnant. The 15-year-old was stabbed by another woman in a quarrel and died on the street, so my 45-year-old client lost not only her daughter but her [unborn] granddaughter as well.”

Abigail, 23, who did not give her surname, gave birth just a few months ago. “I’m not working, my boyfriend isn’t working, and every day is a struggle,” she says. In and out of jail, her boyfriend smokes tik and lacks the identity papers required for work, while Abigail is hoping to return to her temporary work in the vineyards. “Sometimes if we don’t have anything to eat, I have to go and beg,” she says.

Down in Khayelitsha township in the Cape Flats, Dr Ingrid le Roux, who started another mentor mother programme through her NGO, Philani, says alcohol abuse and FAS are huge problems in the million-strong area the organisation serves, as are HIV, tuberculosis, malnutrition, diabetes, stroke, obesity and noncommunicable diseases. Mentor mothers go door to door with scales and folders, plotting babies’ weight and age on a chart until they are five years old, and do referrals to clinics and hospitals if the mother or child are in need of blood tests, retrovirals or medication.

“For us, alcohol is a really big issue – not only because of the risk of foetal alcohol syndrome but because when we pick up a malnourished child, the biggest problem for that child’s rehabilitation is whether there is [continued] alcohol abuse in that child’s family,” says Le Roux.

“We need a partner in that family in order to rehabilitate that child. If there is no partner … then how do we rehabilitate the child?”

Facebook Twitter Pinterest Charay Afrika, far left, and Abigail, centre, in Esselen Park township with other mentor mothers and social workers. Photograph: Kate Hodal/The Guardian

One of Philani’s mentor mothers, Sindiswa Govuza, 47, says the mothers she mentors range in age from 17 to 21, and usually have two or three children each. A government grant of 380 rand [£23] per child means some girls see children as a way to make money, Govuza says. “Often, they give the child to grandparents and go off and party. The teenagers like fancy phones, so they sleep with old men to get the money, or they might binge-drink, get raped and end up with HIV.”

South Africa has steep rates of malnutrition, with 27% of children under five stunted and more than one in three children in Gauteng province, which includes Johannesburg, suffering from stunted growth. In a brick garage-turned-crèche in Alexandra township, a group of two- and three-year-olds play as they wait for their glass of milk and peanut butter sandwich. Orphaned, or born with FAS or low birth weight, these children depend on these meals to survive.

“Their parents are not working, or some of them are HIV-positive, and when they come to fetch their children I can tell they are not well,” says Betty Sithole, whose ACFS charity has been feeding children across the province since 1994. “I started this because I would see so many children who were malnourished or underweight, and I’d bring them here, cook them balanced meals and then got to teaching life skills to the mothers, because some have five or six children and many are single parents.”

Back in Roodewal, Afrika keeps in close contact with her daughter’s teachers and often visits her class. With the support of FASfacts’ mentors, and having gone through rehab, she says her notion of parenting has completely altered. Now pregnant with her third child, and alcohol free, Afrika is looking forward to her forthcoming wedding to a stable, working man, and a healthy lifestyle for her family.

“My priority now is just doing everything I can for my children,” she says. “I have a very strong support network now – I thank God for these changes.”