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Seat belt use among pregnant women in the United Arab Emirates: the Mutaba’ah Study
  1. Aminu S. Abdullahi1,
  2. Yasin J. Yasin1,2,
  3. Syed M. Shah1,
  4. Luai A. Ahmed1,
  5. Michal Grivna1,3
  1. 1 Institute of Public Health, United Arab Emirates University, College of Medicine and Health Sciences, Al Ain, Abu Dhabi, UAE
  2. 2 Department of Environmental Health and Behavioral Sciences, School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
  3. 3 Department of Public Health and Preventive Medicine, Second Faculty of Medicine, Charles University, Prague, Czechia
  1. Correspondence to Professor Michal Grivna, Institute of Public Health, United Arab Emirates University College of Medicine and Health Sciences, Al Ain, Abu Dhabi, UAE; m.grivna{at}uaeu.ac.ae

Abstract

Introduction Motor vehicle collisions are a major cause of death and injury among pregnant women and their fetuses. Seat belt use compliance during pregnancy varies in different populations. We aimed to study seat belt use among pregnant women and factors affecting seat belt use during pregnancy in Al Ain City, the United Arab Emirates.

Methods This cross-sectional analysis used the baseline data collected from pregnant women participating in the Mutaba’ah Study from May 2017 to November 2022. Data were collected using self-administered questionnaires. Variables included sociodemographic, gestation periods and seat belt-related information. All pregnant women who responded to the questions related to seat belt use were included (N=2354).

Results Seat belt use before and during pregnancy was estimated at 69.7% (95% CI 67.9% to 71.6%) and 65.5% (95% CI 63.6% to 67.4%), respectively. The reasons for not using seat belts during pregnancy included being uncomfortable to wear, habitual non-use and considering them unsafe for pregnancy. Age, higher levels of education of the pregnant woman or her spouse, being employed, having a sufficient household income, lower gestational age, and using a seat belt before pregnancy were positively associated with using a seat belt during pregnancy in the bivariate analyses. Pregnant women in their third trimester had independently significant lower odds of using a seat belt compared with those in the first trimester (OR 0.42, 95% CI 0.24 to 0.76).

Conclusions The findings indicate decreased compliance with seat belt use during pregnancy and as gestation progressed. The decrease was related to several reasons, including feeling uncomfortable wearing seat belts, habitual non-use and unsafe for pregnancy, necessitating appropriate measures to increase awareness. Raising public awareness about the advantages of wearing seat belts during pregnancy and the involvement of healthcare professionals in educating pregnant women are warranted.

  • Motor vehicle � Occupant
  • Behavior
  • Attitudes
  • Risk Perception
  • Driver
  • Passenger

Data availability statement

Data are available on reasonable request.

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WHAT IS ALREADY KNOWN ON THIS TOPIC

  • Pregnant women and their fetuses are at risk of traffic-related adverse pregnancy outcomes, injury, trauma and deaths which can be alleviated through the use of seat belt. However, despite legislations mandating the use of seat belt in the United Arab Emirates, compliance in the general population remains relatively low compared with other high-income countries.

WHAT THIS STUDY ADDS

  • Seat belt use among pregnant women is less studied in the Emirati population. It is not known how pregnancy affects seat belt use and the reasons behind non-compliance with seat belt during pregnancy. This study presents a clear understanding of the patterns and changes in seat belt use among Emirati pregnant women.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

  • Understanding seat belt compliance among pregnant women is essential and relevant to planning injury prevention interventions to improve road traffic safety and reduce the associated deaths and injuries. This study presents findings and provides recommendations for informed policies to address seat belt non-use among Emirati women during pregnancy.

Introduction

Motor vehicle collisions (MVCs) are the major cause of death and injury among pregnant women and their fetuses.1–3 Estimates suggest that MVCs account for 21%–98% of trauma in pregnancy,1 which contributes to approximately 14% of maternal and 11% of fetal deaths.4 Furthermore, MVC is associated with adverse pregnancy outcomes, including placental abruption, preterm labour, uterine rupture, caesarean delivery, excessive bleeding and low birth weight.1 4–6 MVCs are predictable and preventable. Seat belts are the most important safety innovation in injury prevention. Their use reduces deaths and injuries associated with MVCs.7 Pregnant women are high-risk groups and are recommended to use seat belts when they travel in motor vehicles.6 Seat belt use during pregnancy reduces adverse maternal and fetal outcomes in the case of MVC.6 8 9 In contrast, unrestrained pregnant women involved in MVCs experience a greater risk of excessive bleeding and fetal deaths.1 4 10–15 Accordingly, compliance and proper use of seat belts are essential to reduce the subsequent injuries that result in adverse outcomes. Healthcare professionals need to be actively involved in educating pregnant women about correct seat belt use.6

In the United Arab Emirates (UAE), seat belt legislation was implemented in 1999 for front-seat passengers.16 As of 2017, it became mandatory for all car passengers.17 Despite this, seat belt compliance remains relatively low in the UAE. Evidence indicated that about 61% of the drivers, 43% of front seat passengers and 12% of rear seat passengers use seat belts in the UAE, which is lower compared with other high-income countries (HICs),18 19 and vehicle occupant mortality in the UAE is higher compared with other HICs, and the global average.20 21 Furthermore, seat belt compliance varied significantly across individual emirates by gender and nationality in the UAE.18 22 A recent study showed that 46% of the drivers and 50% of front-seat passengers use seat belts in the Emirate of Abu Dhabi, with higher compliance in women (56%) and non-UAE nationals (44%).22 However, seat belt use among pregnant women was less studied in the Emirati population. Whether pregnancy alters the use of seat belts in Emiratis is unknown. Understanding seat belt compliance among pregnant women is essential and relevant to planning injury prevention interventions to improve road traffic safety and reduce the associated deaths and injuries. We aimed to study seat belt use among pregnant women and factors affecting seat belt use during pregnancy in Al Ain City, UAE.

Methodology

Study design, settings and participants

This was a cross-sectional analysis of the baseline data collected from pregnant women who participated in the Mutaba’ah Study from May 2017 to November 2022. The Mutaba’ah (meaning ‘follow-up’ in Arabic) Study is the UAE’s largest prospective mother and child health cohort study. The study systematically recruits pregnant women from the Emirati population who are 18 or more years old, residents of Al Ain, and able to provide consent during their antenatal care (ANC) visits at major hospitals in the city. Details of the Mutaba’ah Study have been published elsewhere.23

Data collection and variables

Data were collected using self-administered questionnaires and covered, among others, sociodemographic and pregnancy-related information, involvement in road traffic crashes, and seat belt use. A specific set of questions was dedicated to the measurements of seat belt use. For each of the types of trips (long trips on highways, travelling around the city and short trips around the home), the participants were asked the questions, ‘How often did you use a car seat belt before you became pregnant?’ and ‘How often do you use the car seat belt after you became pregnant?’ with response options including ‘always’, ‘most of the time’, ‘rarely’ and ‘never’. If a woman answered ‘always’, ‘most of the time’ or ‘rarely’, she was considered to be using a car seat belt. To understand the reasons behind not using seat belts during pregnancy, the women were asked ‘If you do not use the seat belt during pregnancy, what are the reasons for not using them?’ with the following multiple options—‘I don’t usually wear a seat belt’, ‘It is uncomfortable’, ‘It is unsafe for my pregnancy’, ‘It is difficult to fasten’, ‘It wrinkles my clothes’, ‘It is dangerous for me’, ‘It is dangerous for my child’ and ‘others’. To assess the use of a child seat, the question, ‘Do you have a child seat in your car now?’ was asked with two possible options, ‘yes’ and ‘no’.

Statistical analysis

Data are presented as numbers (percentages) for categorical variables or median (IQR) for continuous variables. The χ2 test was used to compare categorical data, while the Mann-Whitney U test was used to compare continuous data across categories of seat belt use. Changes in seat belt use before and during pregnancy were tested using McNemar’s and marginal homogeneity tests. Binary logistic regression was employed to quantify the relationship between the explored variables and seat belt use during pregnancy. A multivariable logistic regression model was also performed to rule out the possible confounding effects of other predicting factors. Crude and adjusted ORs were reported with 95% CIs. A p<0.05 was considered statistically significant. Data were analysed with the R software V.4.1.2.

Results

A total of 2354 pregnant women were included in this study. Table 1 shows the general characteristics of the study participants. The women’s median age (IQR) was 30 years (26–35). About 45% (n=1006) of the women had a bachelor’s degree or higher. Among spouses, 51% (n=1051) had a tertiary education. Regarding occupation and income, 71% (n=1572) of the pregnant women were unemployed and 95% (n=1826) had sufficient household income. The median gestational age was 6 months (IQR=4–8). One in 10 (10%) reported being previously involved in road traffic crashes.

Table 1

Characteristics of pregnant women by self-reported seat belt use during pregnancy in Al-Ain City, United Arab Emirates

Overall, seat belt use among women before and during pregnancy was estimated at 69.7% (95% CI 67.9% to 71.6%) and 65.5% (95% CI 63.6% to 67.4%), respectively. The use of seat belts during pregnancy was significantly (p<0.001) more prevalent among pregnant women with higher education or having a husband with higher education. Employed pregnant women (73%) had a significantly (p<0.001) higher percentage of using seat belts compared with the unemployed (62%). Higher use of seat belts during pregnancy was also more frequent among pregnant women with sufficient family income (67% vs 54%, p=0.009), in their first trimester (69% vs 67% in the second trimester vs 62%in third trimester, p=0.014) and seat belt use before pregnancy (93% vs 3.0%, p<0.001).

About 7% (n=123) of women who were seat belt users before pregnancy became non-seat belt users after becoming pregnant. In contrast, 3% (n=24) of women changed their behaviour from non-seat belt users before pregnancy to seat belt users after they became pregnant. These observed changes were statistically significant (p<0.001) (table 1).

Figure 1 compares the frequency of seat belt use before and during pregnancy on highways, in the city and on a short trip. Fewer women reported always using a seat belt during pregnancy compared with before pregnancy on the highway (36% vs 42%), in the city (33% vs 38%) and during short trips (29% vs 34%). In contrast, more women reported not using a seat belt during pregnancy compared with before pregnancy on the highway (37% vs 31%), in the city (39% vs 34%) and during short trips (44% vs 39%).

Figure 1

Proportion of pregnant women using seat belt before and during pregnancy.

Figure 2 shows the common reasons for not using a seat belt during pregnancy. Most (56%) of women thought that seat belt is uncomfortable to wear, 38% stated that they did not usually wear a seat belt and 4% reported that seat belt is unsafe for pregnancy. Moreover, among those who switched to non-use during pregnancy, the most common reasons were lack of comfort (75%) and concerns that it is unsafe for pregnancy (11%). The majority of those who stopped using seat belts during pregnancy were above 30 years old (46%), in their third trimester (47%) and/or were unemployed (75%).

Figure 2

Reasons for not using seat belt during pregnancy. (Percentages add up to more than 100% as subjects could choose more than one option)

Age, higher levels of education of the pregnant woman or her spouse, being employed, having a sufficient household income, lower gestational age, and using a seat belt before pregnancy were positively associated with using a seat belt during pregnancy in the bivariate analyses. However, when using the multivariable logistic regression model, only gestational age was found to have a significant association with seat belt use during pregnancy. Specifically, individuals in the third trimester had significantly lower odds of using a seat belt compared with those in the first trimester (OR 0.42, 95% CI 0.24 to 0.76), as shown in table 2.

Table 2

Bivariate and multivariable logistic regression for factors associated with the use of seat belt during pregnancy

Discussion

In this study, approximately 66% of pregnant women used seat belts. Seat belt compliance decreased during pregnancy as compared with before pregnancy. Compliance was more prevalent among pregnant women with higher education or having a husband with higher education, employment, sufficient family income, lower gestational age and those who used seat belts before pregnancy. The common reasons for not wearing seat belts during pregnancy included being uncomfortable to wear, the habit of not usually wearing seat belts and fear that seat belts are unsafe for pregnancy.

The reported compliance with seat belt use varied in different studies. Although some studies reported reduced seat belt use during pregnancy,8 24–26 others found it increased.27 28 In our study, the use of seat belts decreased during pregnancy and across the trimesters as gestation progressed, similar to other studies.8 24 25 However, seat belt use compliance in this study was low compared with the findings of numerous similar studies in the UK (98%),29 30 the USA (83%–87%),31 Japan (87%)24 and Hong Kong (67%–73%).8 Furthermore, a global study found that 91% of pregnant women wore seat belts, with 95%, 92% and 83% wearing seat belts in Europe, North America and other countries, respectively.32

Over the last two decades, there have been tremendous improvements in injury prevention measures in the UAE, including enforcement of safety regulations (such as seat belts, child restraint, helmets and speed law enforcement) and the use of safety devices (such as seat belt, child restraint and helmet use). Despite these efforts, seat belt compliance remains low in the population,18 19 22 which is also reflected in the current study.

The low seat belt use compliance among pregnant women in our setting is of great concern as it puts two lives at risk.30 Studies have shown that pregnant women who did not wear seat belts were more likely to experience adverse maternal and fetal outcomes in a crash.1 4 10–15 33 For example, a study from New Mexico, USA, showed that 77% of pregnant women killed in car crashes were unrestrained at the time of the collision.33

The reported changes in seat belt use during pregnancy are related to several reasons, including uncomfortable to wear and concerns about the safety of the pregnancy, which is consistent with previous studies.6 8 25 This may explain the misconception about the effects of seat belt use on pregnancy and the fetus6 8 and demonstrates a possible lack of understanding of the adverse outcomes of unrestrained crashes.6 30 34 These beliefs and misconceptions constituting a barrier to the use of seat belts among pregnant women call for targeted and informed education and awareness campaigns, including health talks delivered at ANC clinics. Such campaigns should specifically be tailored to demystify the misconception that seat belt is harmful and make pregnant women understand and prioritise the benefits of seat belt use over mere comfort.

On the other hand, our study has shown that higher education and the habit of using seat belts before pregnancy are significant factors associated with seat belt use among pregnant women, similar to previous studies.6 8 31 35 36 This may be because women with higher educational attainment and a habit of using seat belts may have a higher risk perception of danger and may understand the safety benefits of seat belts. In contrast, the opposite was noticed in those with lower education and habit of non-seat belt use before pregnancy. Understandably, measures targeting increased seat belt use compliance in these special population groups need appropriate educational considerations.34

Strengths and limitations of the study

This is the first study to explore car seat belt use among pregnant women in the UAE. The large sample size of pregnant women who answered the seat belt use set of questions strengthens the study. The study included a representative sample of pregnant women from the Emirati population as participants were recruited from major public and private hospitals in the city, and all the Emirati population has the same full health insurance coverage allowing them to have the same level of healthcare in all health facilities. Our study has several limitations. First, our study is from a single city and may not represent the whole UAE. Second, the analysis did not include data on smart seat belt reminders. Numerous studies found significant differences in seat belt use between cars with and without seat belt reminders.37–39 Some important factors such as marital status (married status vs divorced/widowed), gravida status (primigravida vs multigravida), driving license (holder vs non-holder), drug/alcohol use, smoking status, passenger seat (front seat vs rear seat), husband driving license (holder vs non-holder) and husband occupation were not included in the analysis. Third, our study did not include the mode of travelling. Some women may use public buses, which do not require a seat belt. Fourth, reporting bias is another concern. Previous studies highlight a profound difference between observed and self-reported seat belt use.40–45 This may lead to an under or overestimate of actual practices. Fifth, knowledge of pregnant women on mandatory seat belt law was not included. Finally, this study is a cross-sectional study design, which neither addresses seasonality nor establishes the causal relationship.

Conclusions

The findings indicate decreased compliance with seat belt use during pregnancy and as gestation progressed. This decrease can be attributed to various factors, including discomfort while wearing seat belts, the habit of not using them and the misconception that seat belt use is unsafe during pregnancy. Greater efforts are required to raise public awareness about the advantages of wearing seat belts during pregnancy. Moreover, involving healthcare professionals in educating pregnant women about this matter is crucial. Taking appropriate measures that ensure compliance with seat belt use among pregnant women will be beneficial in terms of reduced healthcare costs and in safeguarding the health and lives of both the mothers and their fetuses.

Data availability statement

Data are available on reasonable request.

Ethics statements

Patient consent for publication

Ethics approval

Ethical approval was obtained from the United Arab Emirates University Human Research Ethics Committee (ERH-2017-5512) and the Abu Dhabi Health Research and Technology Ethics Committee (DOH/CVDC/2022/72). Written informed consent was obtained from the study participants to use the data for this study.

Acknowledgments

The authors would like to acknowledge and thank all the participants of the Mutaba’ah study.

References

Footnotes

  • Twitter @dr_michalgrivna

  • Contributors LAA and MG contributed to the study’s conception and design. ASA, LAA and MG contributed to the acquisition and coding of data. ASA analysed the data. ASA and YJY drafted the manuscript. LAA, SMS and MG critically edited the paper. All authors read and approved the final version of the manuscript. MG and LAA are the overall content guarantors.

  • Funding This work was supported by a grant from the Zayed Center for Health Sciences, United Arab Emirates University (31R183).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.