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OBJECTIVE: To evaluate current knowledge and practice among pregnant
women about the use of car restraint systems during pregnancy.
Design:
A structured questionnaire.
Setting:
District hospital antenatal clinic.
Participants:
Two hundred pregnant women attending for their routine mid pregnancy
anomaly scan.
Main outcome
measures:
The women were asked about seatbelt and airbag usage, source
of information about restraint systems and the legal requirements
and recommendations regarding car safety systems.
Results: One
hundred fifty-nine women (80%) completed the questionnaire. Ninety-eight
percent wore seatbelts in the front, 68% wore seatbelts in the back
of the car, 48% correctly identified where to place the seatbelt
and 37% had received information on seatbelt use while pregnant.
The latter were more likely to correctly position their restraints
than those who had received no information (P = 0.03). Thirty-nine
percent had an airbag system fitted and one woman had de-activated
it. Fifty-eight percent were aware that seatbelt use was a legal
requirement for drivers and passengers when fitted.
CONCLUSIONS:
Many
pregnant women are ignorant of the correct usage of seatbelts, their
positioning and legal requirements. This puts their own well-being,
and that of the fetus, at risk. Women should receive written instruction
and advice from well informed health professionals and be encouraged
always to wear a correctly positioned seatbelt. Education increases
compliance and correct usage.
INTRODUCTION:
Lavenne developed the seatbelt in France in 1903 for use in aeroplanes
and it was adopted for use in motor racing. From this approach evolved
a standard three point restraint fitted in automobiles today1.
Accident investigation and research work published by De Haven entitled
'Injuries and death by car collision' in the 1950's identified that
in 25% of serious accidents, death was caused by ejection from the
car1. Adoption of the three-point seatbelt has decreased
deaths from road traffic accidents by 45% and moderate to critical
injuries by 50%2. It became a statutory requirement to
use seatbelts in the UK in 1983 in the front seats, and rear seats
in 1991. The Department of Transport estimated that 200 lives and
7000 serious injuries a year are avoided by the compulsory use of
seatbelts in front seats and that 100 deaths a year and 1'000 major
injuries are prevented when rear seatbelts are used in conjunction
with front seatbelts 3.
Trauma from motor accidents occurs in 2-3% of pregnancies, 90% of
which are of a minor nature. Fetal loss is reported as occurring
in 1-3%4 6 and pregnancy outcome appears related to seatbelt
use in car accidents 7-12. In 1971, Crosby et al. reported
that the major cause of fetal death in an accident was maternal
death and this was significantly reduced by wearing a seatbelt.
Fetal survival was improved if a three-point seatbelt rather than
a lapbelt alone was worn 1,13,14. The American College
of Obstetricians and Gynaecologists issued guidelines on seatbelt
usage for pregnant women in 1991 15. Subsequent audit
in the USA and Australia suggests many pregnant women are not complying
with these recommendations 16-21. The 1998 report 22
on confidential enquiries into maternal deaths in the United Kingdom
1994-1996 has made recommendations for the UK for education and
training of pregnant women and health care workers including:
1. The shoulder belt should go over the shoulder, collar bone and
down and down across the chest, between the breasts.
2. The lap belt should be worn as low as possible under the abdomen
and the unborn child.
3. Always wear a full seatbelt.
The purpose of this study was to determine the pattern of use and
knowledge in the UK among pregnant women regarding seatbelts, airbags
and current legislation. We asked for their sources of information.
METHOD The questionnaire was given to 200 women presenting
consecutively for their routine mid-pregnancy anomaly scan at York
District Hospital. For most women, this was their first hospital
appointment, as the majority book in the community with midwives
and general practitioners. At the booking visit, it is routing to
give general pregnancy advice, and primigravidae are given in the
Health Education Authority pregnancy book. The survey size was chosen,
in the absence of reliable data, pragmatically to give both a manageable
number for collection and analysis within a finite time. Each woman
was asked to complete a 51 question survey regarding use and knowledge
of seatbelts and airbags while pregnant, whether they had received
any information on this topic in pregnancy and their sources of
information. On leaving the antenatal clinic, all the pregnant women
were given an information leaflet detailing the current legal position
and guidance for the correct use and positioning of seatbelts
23. We advised them not to deactivate airbags if fitted. The
survey, submitted to and approved by the local ethics committee,
was performed August-October 1998 before the release of the report
on confidential enquiries into maternal deaths in the United Kingdom
1994-1996.
RESULTS Eighty percent (159/200) of the pregnant women with
a mean gestation of 19 weeks and mean age of 29.4 years completed
the questionnaire. Of these, 75/159 (47%) were multiparous. There
was no difference in replies between primigravidae and multiparae.
Eighty-one percent (125/159) were qualified drivers, 125/159 (76%)
were currently employed, and 47/159 (30%) needed to drive in their
employment. Seventy-nine percent (125/159) could drive, of whom
96% (152/159) thought that seatbelts saved lives in car accidents.
Eighty-seven percent (138/159)thought that wearing seatbelts was
beneficial to them if they were involved in an accident when pregnant,
while 89/159 (62%) thought that seatbelts were beneficial to the
fetus in the same circumstances. Eighty seven percent (138/159)
knew that three point seatbelts were safer for them than a lapbelt
and 118/159 (74%) knew that a three point seatbelt was safer than
a lapbelt for the fetus. Three percent (5/159) had been involved
in a road traffic accident while pregnant. Fifty-eight percent (93/159)
correctly responded that seatbelt use was a legal requirement. Drivers
(82/125) were significantly more aware than on drivers (11/34) that
wearing a belt was a legal requirement. Ninety-eight percent (156/159)
always wore a seatbelt in the front seats and 69% (109/159) always
wore a seatbelt in the back seat. The most common reasons for not
wearing a seatbelt in the back seat were discomfort, 22% (11/50),
and concerns about harming the fetus, 30% (15/50). Three subjects
did not have seatbelts fitted in the rear passenger seats. One person
had a medical exemption certificate. Forty-eight percent (77/159)
identified the correct position for both components of the three
point seatbelt while 37% (50/159) could recall being advised on
the correct positioning of seatbelts. This latter group had a 66%
(33/50) correct response rate, significantly different (X2test
P=0.003) when compared with women who could not remember receiving
any information, 40% (44/159). Drivers (68/125) were more likely
to wear seatbelts than non-drivers (8/34) (X2test
P=0.001). The most common information sources were the Health Education
Authority pregnancy book and health leaflets (17% and 8% respectively)
followed by midwives (6%), friends (4%) and magazines (4%). Doctors,
police, newspapers and broadcasting were identified as sources by
less than 1% of women Six women (4%) purposely put their lapbelt
component across their abdomen. Thirty-nine percent (62/159) of
women had airbag systems fitted to the steering wheel, and 20/159
(13%) had front passenger airbags fitted. One person had deactivated
the airbag system. Seventy-one percent (113/159) thought that airbags
increased the safety of a pregnant woman in an accident, and 27/159
(17%) thought that they were potentially dangerous to a pregnant
woman.
DISCUSSION: Motor vehicle accidents are a significant contributor
to deaths in pregnancy. Thirteen of 36 fortuitous deaths occurred
as a result of road traffic accidents in the most recent triennial
confidential enquiry report into deaths in pregnancy 22.
Fortuitous deaths are deaths from non-obstetric causes which happen
in pregnancy or puerperium but are not considered related to the
pregnancy. Studies have unequivocally demonstrated that seatbelts
and other restraint systems reduce mortality and critical injury
following road traffic accidents for driver and passengers
1,7,9,10,13, 14, 24. This is reflected in current legislation,
which makes their use compulsory, with limited exceptions including
taxi drivers with fare paying passengers, drivers of local delivery
vehicles and holders of medical exemption certificates. Airbags,
when fitted, benefit both driver and front seat passenger in frontal
crashes. The reduction of mortality is in the region of 18% with
airbag as a sole safety restraint2. When used in conjunction
with the three point seatbelt, the likelihood of adult fatalities
is reduced by 58% compared with a 53% reduction with seatbelt alone
in otherwise fatal crashes of unbelted drivers20. The
common injuries secondary to airbag deployment are usually minor
and include erythema and abrasions2, 25, 26. While the
three-point seatbelt system is recognised as beneficial to the pregnant
woman and her fetus in preventing maternal death1, 13, 14,
the benefits or airbags in pregnancy are less clearly established.
There is a possibility of increased fetal risk with the explosive
discharge of an airbag activation due to the increased girth of
pregnant women Current recommendations, however, are not to deactivate
the airbag due to the perceived increased maternal protection they
afford15, 20. Thirty-nine percent of women surveyed had
airbags fitted in their cars. This figure will rise as most new
cars come with airbags fitted as standard, at least for the driver.
The majority of our sample population thought airbags were beneficial.
Our study shows a difference in maternal compliance with current
legislation dependant upon whether positioned in the front or rear
of the car. Ninety-eight percent of women chose, at al times to
wear front seat restraints. However, only two in three women chose
to use seatbelts in the back seats. This is illegal and less safe
for the mother and dangerous for the front seat occupants 3,
27. The most common reasons given for not wearing a seatbelt
in the rear seats, discomfort and fear of harming the fetus were
similar to previous research 5, 19. A survey 28
of a largely Hispanic population, selected in part on heir level
of educational attainment, in California revealed poor knowledge
of seatbelt use in pregnancy. Although there was high compliance
with legislation, many were worn incorrectly. Few members of this
population received information from health care providers. Benefit
in terms of correct positioning was found from providing information
early in pregnancy, though this was not recalled by over 70% of
women when re-surveyed after three months. However, both this survey
and our own rely on the women's answers to the questionnaire, unsubstantiated
by independent observation of their seatbelt wearing practice. This
may lead to bias. Other surveys from the United States, where 44.6%
of respondents always wore front seatbelts 5, have used
objective photographic evidence to assess front seatbelt compliance.
Only 58% of our respondents were conversant with current legislation
regarding seatbelt use, although 82% were qualified drivers. This
information is well publicised and documented in the recommendations
of the Highway Code on which all qualified drivers have been tested.
The recommendation for the United Kingdom in the current mortality
report for wearing a three-point seatbelt is: the shoulder belt
should go over the shoulder, collar bone and down across the chest,
between the breasts. Wear the lap belt as low as possible under
the abdomen and the unborn child. Always wear a full seatbelt
22. This accords with other published recommendations 3,
15, 20, 28-31. This positioning was initially adopted following
case reports of injuries sustained when the lapbelt component was
placed across the gravid abdomen 9,32,33. Pearlman and
Viano 20, using an inanimate model known as a 'pregnant
crash test dummy', have confirmed this strap position as the optimum
to reduce the likelihood of injury to both maternal and fetal compartments.
Over half of the respondents could not identify the correct position
for both components of a three-point seatbelt. Other studies have
shown that up to 22% of women were purposefully wearing the lapbelt
portion over the pregnant abdomen 5, 19, 30. There was
a significant difference in correct placement of the seatbelt between
those that recalled receiving advice or information and those who
had received no instruction. Education has been shown to increase
correct belt positioning 5, 18, 19 where up to 77% correctly
wore the seatbelt after instruction. Pearlman and Phillips 5,
suggest that a 1-2 minute discussion accompanied by a simple written
instruction is sufficient. Maternity units in the UK have been reported
as giving variable quality and quantity of information to pregnant
women on seatbelt use. Some advice was considered dangerous by the
authors 29. General practitioners surveyed in Ireland
felt that they were able to give advice but rarely volunteered information
34. Surveys of midwives and general practitioners in
West and North Yorkshire in late 1998 suggests incomplete knowledge
involving car restraint systems (H.C. Johnson and D.W. Pring, unpublished
data). Pregnancy magazines and pregnancy information books 35
for the expectant mother focus predominantly on post-natal child
restraint systems and little is written to highlight correct use
of car restraints in pregnancy, possibly reflecting commercial interests
of advertisers in the many publications.
York has neither major social deprivation nor a large ethnic minority
community. Seventy-six percent of the respondents to the survey
were employed. Responses may be different in areas with a different
demographic distribution and this merits further investigation.
There is a need for further information and research about pregnancy
and airbag safety systems. A prospective audit of outcomes of pregnant
women attending Accident and Emergency departments after motor vehicle
accidents should be considered, especially in cases where there
has been airbag deployment. There should be follow-up of the babies
to determine the immediate outcomes and long term sequale in non-fatal
accidents as there is evidence to suggest an increased risk of fetal
growth retardation 12 and possible neurological handicap
36. Inanimate studies with a modified pregnant crash
test dummy, incorporating a placental unit 20 may determine
ways of limiting placental bed injury, a cause of intrauterine death.
CONCLUSION
A correctly fitted seatbelt should be worn in pregnancy to reduce
risk of maternal and fetal morbidity and mortality. We have shown
a failure of women to wear seatbelts in the rear seats as well as
ignorance regarding approved seatbelt positioning and current legislation.
Education appears to be an effective and simple way to achieve compliance
with guidelines for belt use. Advice should be given as early as
possible in pregnancy and repeated at intervals to emphasise its
importance. A nationwide awareness programme for both health care
professionals and pregnant women should be considered to encourage
the correct positioning and universal seatbelt usage. Publications
targeting pregnant women should stress the importance of in-car
safety for the pregnant woman and her fetus as well as for the newborn
and infant passenger.
Acknowledgements:
The authors would like to thank all the staff at York District Hospital
and Antenatal Clinics for their help and enthusiasm.
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Correspondence:
Dr D. W. Pring, Department of Obstetrics and Gynaecology,
York District Hospital, Wiggington Road, York YO3 7HE, UK
© RCOG 2000 British Journal of Obstetrics and Gynaecology
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