Adapting and Testing a Behavioural Intervention to Prevent FASD and Adverse Infant Outcomes (MaRISA+)

South Africa (SA) has a long history of social and health disparities, resulting in the world's highest rate of fetal alcohol spectrum disorder (FASD; 111.1 per 1,000), where lifelong negative cognitive and physical effects result from prenatal alcohol exposure. FASD is completely preventable if women do not drink during pregnancy. Prenatal alcohol use frequently co-occurs with other substance use, especially tobacco and cannabis. The adverse effect on birth outcomes by alcohol and tobacco use together is worse than either substance alone. Recent evidence from animal models shows that prenatal exposure to both cannabinoids and alcohol potentiate the likelihood of alcohol-induced birth defects.

Data from Cape Metropole, SA, showed that all women who reported prenatal alcohol use also tested positive for tobacco use, with 25% also reporting cannabis use. Alcohol use while breastfeeding also occurs at a relatively high rate in SA. Despite tremendous health benefits from breastfeeding,maternal alcohol use while breastfeeding significantly compromises infant development. Contingency management (CM) has been efficacious in reducing prenatal cocaine, alcohol, and tobacco use in the United States (U.S.). The Women's Health CoOp (WHC) is an evidence-based brief intervention addressing women-focused syndemic issues and resulting disparities associated with substance and alcohol use. These evidence-based interventions need to be combined and adapted for addressing maternal polysubstance use and associated health and behavioral issues during pregnancy and lactation in SA. The Specific Aims are as follows: (1) R61 Aim 1- Conduct formative qualitative research with women who are pregnant or breastfeeding with a recent history of polysubstance use, clinic and community stakeholders, and an established Community Collaborative Board. (2) R61 Aim 2-Test feasibility, acceptability, and appropriateness of the adapted intervention with 48 women (24 pregnant and 24 breastfeeding) in Cape Metropole, SA. (3) R33 Aim 1-Examine the effectiveness of the adapted intervention (i.e., CM and text-based support with WHC educational components) in a 2-group randomized controlled trial with 184 women who are pregnant and follow up during pregnancy and 3 months postpartum. (4) R33 Aim 2-Examine the impact on gestational, birth, and infant outcomes. (5) R33 Aim 3-Track cost and conduct preliminary cost-effectiveness analyses.

Study Overview

• Status: Completed
• Conditions: Alcohol Drinking; Maternal Behavior; Fetal Conditions
• Intervention / Treatment: Behavioral: Intervention with contingent incentives and text-based support

• Study Type: Interventional
• Enrollment (Actual): 48
• Phase: Not Applicable

Contacts and Locations

Study Locations

• South Africa
  • Cape Town, South Africa
    • South African Medical Research Council

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes

Description

Inclusion Criteria:

For key informant interviews in R61 To be eligible, women must (1) 18 or older, (2) be pregnant or breastfeeding with less than 12 months postpartum, (3) report alcohol use , (4) report tobacco or cannabis use

For testing in R61,

1. be in the second trimester of pregnancy or breastfeeding with less than 3 months postpartum,
2. test positive in alcohol use by urinalysis (i.e., EtG),
3. test positive in tobacco or cannabis use by urinalysis (i.e., cotinine and THC),
4. be over 18 years old
5. have a negative HIV test,
6. not be eligible for PrEP
7. plan to complete antenatal care at the current clinic and remain in the area for at least 3 months
8. own a cell phone to receive text messages.

Exclusion Criteria:

- (1) women who report serious medical problems threatening their current pregnancy or current suicidal thoughts or attempts in the past month. These women will be provided necessary referrals.

(2) Women who participated in interviews.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Prevention
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Double

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Intervention; Contingent incentives on abstinence from alcohol, tobacco, and cannabis; Text-based support based on educational components	Behavioral: Intervention with contingent incentives and text-based support; Contingent incentives on abstinence from alcohol, tobacco, and cannabis; Text-based support based on educational components
Active Comparator: Usual Care; Community treatment referrals	Behavioral: Intervention with contingent incentives and text-based support; Contingent incentives on abstinence from alcohol, tobacco, and cannabis; Text-based support based on educational components

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Participants With Negative Urinalysis for Alcohol Metabolite (EtG)	An alcohol metabolite (EtG) will be measured in urine samples. EtG can be detected in the urine up to 5 days after heavy drinking and up to 2 days after light drinking. The dipstick testing will have ≥300 ng/mL as a cutoff value.	3-month postpartum
Number of Participants With Negative Urinalysis for Nicotine Metabolite (Cotinine)	Biochemical verification of recent tobacco use in urine samples. A tobacco metabolite (cotinine) will be measured in urine samples. The metabolite can be detected up to 3-4 days after use. The dipstick testing will have ≥200 ng/mL as a cutoff value.	3-month postpartum
Number of Participants With Negative Urinalysis for Cannabis Metabolite (THC)	Biochemical verification of recent cannabis use in urine samples. A cannabis metabolite (THC) will be measured in urine samples. The metabolite can be detected up to 28 days after heavy use. The dipstick testing will have ≥50 ng/mL as a cutoff value.	3-month postpartum
Number of Days in the Past 7-day Alcohol Use	The number of days in the past 7 days that participants used alcohol.	3-month postpartum
Number of Days in the Past 7-day Tobacco Use	The number of days in the past 7 days that participants used tobacco.	3-month postpartum
Number of Days in the Past 7-day Cannabis Use	The number of days in the past 7 days that participants used cannabis.	3-month postpartum

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of Days in the Past 7-day Cannabis Use While Breastfeeding	The number of days in the past 7 days that participants used cannabis while breastfeeding.	3-month postpartum
Number of Days in the Past 7-day Tobacco Use While Breastfeeding	The number of days in the past 7 days that participants used tobacco while breastfeeding.	3-month postpartum
Number of Days in the Past 7-day Alcohol Use While Breastfeeding	The number of days in the past 7 days that participants used alcohol while breastfeeding.	3-month postpartum

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Birth Weight (g)	birth weight of infants among participants who entered the study during pregnancy	at birth
Birth Length (cm)	birth length of infants among participants who entered the study during pregnancy	at birth
Gestational Age (Weeks)	Gestational age of infants among participants who entered the study during pregnancy	at birth
Head Circumference (cm)	Head circumference of infants among participants who entered the study during pregnancy	at birth

Collaborators and Investigators

• Sponsor: RTI International
• Collaborators: Medical Research Council, South Africa
• Investigators: Principal Investigator: Yukiko Washio, PhD, RTI International

Study record dates

Study Major Dates

• Study Start (Actual): April 1, 2023
• Primary Completion (Actual): September 10, 2024
• Study Completion (Actual): October 31, 2024

Study Registration Dates

• First Submitted: January 30, 2023
• First Submitted That Met QC Criteria: February 17, 2023
• First Posted (Actual): February 28, 2023

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: February 7, 2025
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Drinking Behavior; Alcohol Drinking
• Other Study ID Numbers: EC025-11/2022

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: After the main findings are published, we welcome other researchers who want to analyze the data in other ways.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; CSR

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No