Background Road traffic injuries are the leading cause of death for children over five, and these deaths occur predominantly in low- and middle-income countries (LMICs). Despite the proven effectiveness of child restraints in reducing mortality by 60%, utilization rates are critically low in these regions. Unfortunately, child restraint use is extremely low in LMICs, with rates below 10% in some Latin American countries. Moreover, the WHO has no child restraint use data in major regions including Africa, Eastern Mediterranean, and South-East Asia. This study, funded by the Bloomberg Philanthropies Initiative for Global Road Safety, evaluates child restraint usage across nine global cities.

Methods Observational data were collected in eight rounds from February 2015 to March 2019, in Accra, Addis Ababa, Bandung, Bangkok, Bogota, Fortaleza, Ho Chi Minh City, Mumbai, and Sao Paulo. Observations included the child’s age, use of child restraint, seat position, vehicle type, day, and road type.

Results From 43,619 observations, the prevalence of child restraint use was 16.23% for under-fives and 3.24% for ages five to eleven. Sao Paulo had the highest under-five usage at 53.54%, and Bandung had the lowest, at 2.23%. Children over five showed the highest restraint usage in Bangkok and Sao Paulo, both above 16%, while the remaining cities fell below 10%. Sedans and SUVs had higher restraint usage rates, with lower rates noted on Fridays and on local roads. A significant number of children were improperly seated in the front seat.

Conclusion The low and variable rates of child restraint use in these nine cities highlight a critical public health issue. Potential barriers to child restraint use include availability, affordability, and lack of necessary infrastructure, such as seat belts in older vehicles. The ongoing analysis aims to identify factors influencing restraint use and track changes over time. The findings underscore the urgency for improved vehicle standards and stronger policies to enhance child passenger safety globally.