Review on Safety of Pregnant Occupant Travelling With or Without

Designed by: Publication Unit, Miros

MRev 02/2009

MIROS Review Report

Khairil Anwar Abu KassimNoor Faradila Paiman

Review on Safety of Pregnant OccupantTravelling With or Without

Restrant in a Passenger Vehicle

MALAYSIAN INSTITUTE OF ROAD SAFETY RESEARCH

Malaysian Institute of Road Safety Research Lot 125-135, Jalan TKS 1, Taman Kajang Sentral43000 Kajang, Selangor Darul EhsanTel +603 8924 9200 Fax +603 8733 2005Website www.miros.gov.my Email [email protected]


MIROS Review ReportMRev 02/2009

Review on Safety of Pregnant Occupant Travelling With or Without

Restraint in a Passenger Vehicle



For citation purposes

Khairil Anwar AK & Noor Faradila P (2009) Review on Safety of Pregnant Occupant Travelling With or Without Restraint in a Passenger Vehicle, MRev 02/2009, Kuala Lumpur: Malaysian Institute of Road Safety Research.

MIROS © 2010 All Rights Reserved

Published by:

Malaysian Institute of Road Safety Research (MIROS)Lot 125-135, Jalan TKS 1, Taman Kajang Sentral,43000 Kajang, Selangor Darul Ehsan, Malaysia.

Printed by : Publication Unit, MIROSTypeface : Goudy Old StyleSize : 11 pt / 15 pt

DISCLAIMERThe information contained in the report is restricted and/or privileged information and is intended only for authorised screening and/or confidential presentation of MIROS’s discretion. This report should not be disseminated, modified, copied/plagiarised or action taken in reliance upon it, unless permitted by MIROS. None of the materials provided in this report may be used, reproduced or transmitted, in any form or by any means, electronic or mechanical, including recording or the use of any information storage and retrieval system, without written permission from MIROS. Any conclusion and opinions in this report may be subject to reevaluation in the event of any forthcoming additional information or investigations. MIROS declares that all the inquiries which MIROS believes are necessary and appropriate and that nothing significance which MIROS regards as relevant have, to MIROS knowledge, been withheld from the report.

Perpustakaan Negara Malaysia Cataloguing-In-Publication Data

Khairil AnwarReview on safety of with or without restraint in a passenger vehicle / Khairil Anwar Abu Kassim, Noor Faradila Paiman.(MIROS review report ; Mrev 02/2009)Bibliography: p. 20ISBN 978-983-44643-7-0 1. Traffic safety. 2. Automobiles--Occupant restraint system. 3. Traffic safety.I. Noor Faradila Paiman. II. Title. III. Series.363.125

Team MembersMohd Hafzi Md IsaAzhar HamzahZulhaidi bin Mohd Jawi@SaidMohd Syazwan SolahAqbal Hafeez AriffinMohd Khairudin Rahman

Research ParticipantsRohayu SaraniAimi Mohd FahmiSiti Hasnah HamzahSalina MustaffaNorashikin Mohd Arshad

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MRev 02/2009

Contents

Acknowledgement vii

Abstract ix 1.0 Introduction 1 2.0 Prevalence of Seatbelt Use 3 3.0 Risk of Injury 5

3.1 Mother–To–Be Injury and Mortality 5 3.2 Foetal Injury and Mortality 8 4.0 Anthropometric of Pregnant Women 10

5.0 Crash Simulation Model of the Pregnant Women Occupant 11 6.0 Traffic Legislations 14

7.0 Recommendations 15

8.0 Conclusions 18

References 20

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MRev 02/2009Review on Safety of Pregnant Occcupant Travelling with or Whithout Restraint in a Passenger Vehicle

Acknowledgement

We would like to thank the staff of the Malaysian Institute of Road Safety Research, especially those who were pregnant at the time of this review, who were a tremendous source of information on the discomforts of driving using a seatbelt. We would also like to express our gratitude to Dr Wong Shaw Voon, Director of Vehicle Safety and Biomechanics Research Centre for his support and guidance. Our appreciation also goes to Prof Dr Ahmad Farhan Sadullah, Director General of Malaysian Institute of Road Safety Research for his support.

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Abstract

A myth exists that warns pregnant women not to use seatbelts because it could kill their unborn babies. However, there is currently no scientific evidence to support the idea that pregnant women travel more safely without using seatbelts. In fact, there are more risks if pregnant women travel by car without buckling up their seatbelts. Many researchers had proven that seatbelt wearing could save many lives including pregnant women and their unborn baby. Researchers had also suggested that pregnant women should use seatbelts properly in order to avoid injuries to them and to their unborn child during a collision. However, there are some challenges to automotive engineers in designing safety belt for pregnant women; 1) how to prevent the lap belt from riding up over a pregnant woman’s abdomen as she drove, and 2) how to acommudate the changing pregnant woman’s body with increase gestational age. Nevertheless, the study on the safety of pregnant women is scarce globally. This is due to the difficulty of getting data on pregnant women as the population is small and the statistical number involved in a crash is even lesser. Thus, the importance of seatbelt use during pregnancy is not given due recognition. As a result, the amount of information on seatbelt use during pregnancy is low and could therefore be the reason for many misconceptions on the importance of seatbelt use during pregnancy.

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1.0 Introduction

During pregnancy, all pregnant women are concerned about avoiding anything that may harm their babies. Naturally, all women want to see the baby they are expecting to be delivered safely. However, in a modern society, most of the mother-to-be are career women and they cannot stay at home during pregnancy. As long as it is comfortable and safe, they can get into a car right up until the end of pregnancy. However, do they have adequate information and the precaution any measures before they get behind the wheel? The study in the UK by Acar et al. (2003) reported that only 13% of pregnant women wear their seatbelt in the correct position as prescribed by the National Highway Traffic Safety Administration (NHTSA) guidance.

A simple survey carried out among pregnant women in MIROS on seatbelt use by vehicle occupants showed that all pregnant women in MIROS use their seatbelt every time they were on the road. However, they needed to adjust their seatbelt while driving so that the seatbelt strap restrained their body comfortably. Some women complained that they began to feel uncomfortable in the last trimester when the baby moved more often. They also complained about feeling the pressure of the strap. Therefore some of them used a strap stopper to gain more comfort. But, is the strap stopper safe? Even though no test has been done on the use of the strap stopper, its use could reduce the effectiveness of a pre-tensioner; especially for cars that are equipped with airbags. The effect of the strap stopper during actual crash is something important to be observed.

Some pregnant women believe that it could be unsafe to use seatbelts while travelling on the road. There are concerns that the seatbelt strap might injure their baby. Some choose to protect the unborn child by not wearing a seatbelt. Consequently, there are rumours that warn pregnant women not to use seatbelts because it could harm their unborn babies. Perhaps this is a general tendency to accept a myth rather than looking into the matter scientifically. There is currently no scientific evidence to support the idea that pregnant women travel safer without using the seatbelt. Kratzke (2006) from the National Highway Traffic Safety Administration (NHTSA) reported that in 2005, James E. Hofferberth petitioned that the Federal Motor Vehicle Safety Standards (FMVSS) No. 208 be amended (Occupational Crash Protection) that a pregnant woman should not use the existing seatbelt. He recommended

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Review on Safety of Pregnant Occcupant Travelling with or Whithout Restraint in a Passenger Vehicle MRev 02/2009

placing a placard on new passenger vehicles to warn pregnant occupant not to use seatbelt. Mr. Hofferberth believed that seatbelt may cause injury to pregnant women and their unborn foetus in crash or non crash situation. However, Hofferberth never submitted any reliable data to prove his statement.

The major challenge to be considered during the seatbelt design is how to prevent the lap belt from riding up over the pregnant women’s abdomen as they drove. As gestational age increases, the lap belt portion generally becomes more horizontal (Klinich et al. 1999) and tend to shift up over the expecting mother’s abdomen. Acar et al. (2004) has enhanced this study by exploring the way of providing data to automotive engineers on accommodating pregnant occupant anthropometry. It is important to improve seatbelt use and its positioning due to the altered pregnant woman body.

The lack of data on safety of pregnant women and their unborn babies in car crashes has resulted in much misinformation. This is probably due to small number of population of pregnant women and hence, the study on the importance of using seatbelt during pregnancy has not been given due recognition. Pregnant women are still in doubt if a seatbelt is helpful in a car accident or if it might injure the unborn baby in some way. They are unaware of the safest behaviour as drivers or passengers in terms of seatbelt use, and the real risks of not using this basic protection system. A study conducted by Nakahara (2007) from Japan on the content of maternity and baby magazines shows that the amount of information on seatbelt use during pregnancy was low. The information gap might be the reasons of misunderstanding on the importance of seatbelt use during pregnancy. Thus, the objectives of this report are to:

• make clear the benefits of seatbelt and its importance for pregnant car occupants; and

• provide guidelines on the correct way to buckle up for pregnant women.

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2.0 Prevalence of Seatbelt Use

There are many researchers are reporting on the importance of seatbelt use among reproductive aged women. Crosby in 1971 showed the significance of using seatbelt while travelling for pregnant women. In his study, he stated that “the mortality rate in pregnant women not wearing a seatbelt is double that of those not using one” (Crosby et al. 1971). The following year, the American Medical Association had recommended pregnant women to use seatbelt every time they get in a motor vehicle (JAMA 1972). The American College of Obstetricians and Gynecologists in 1991 had outlined the right way for pregnant women to use seatbelts (ACOG 1991). The same advice had been emphasised in the recent study by Pearlman et al. (Pearlman et al. 2008) in his study concerning maternal restraints and foetal injuries.

There are several of researchers reporting on the prevalence of seatbelt use among reproductive-aged women.

Hyde 2003 had studied on the characteristics that determine the choice using seatbelt among pregnant women. It can be seen that the charecteristics of belted and unbelted mothers differed as shown in Table 1. the data in Table 1 shows that the level of education of mothers determines the use of seatbelt. Their behaviours such as if they smoke during pregnancy and/or consume alcohol had also influenced their choice of seatbelt use.

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Table 1 Characteristics of unbelted versus belted women in crashes (Hyde et al. 2003)

Unbelted (n=1099) Belted (n=7143)

Age (y) 23.9* 25.8

Race (% white) 95.4 96.0

Completed high school (%) 73.2* 88.1

Smoking (%) 21.2* 9.8

Alcohol (%) 2.6* 1.6

No. of previous births 1.2 1.2

Received care first trimester (%) 78.2* 85.5

Weight gain [kg (lb)] 14.0 (30.8) 13.9 (30.7)

* Significant at p<0.05 level

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3.0 Risk of Injury

Royal Automobile Club of Spain (RACE) illustrated the phenomena of vehicle collision in their 2006 report (RACE 2006). They mentioned that there are three different collisions in our event of a road crash. The first is the collision between a vehicle against another object. The second occurs between the occupants and interior object of the vehicle. While the third collision may occur when the soft internal organ of the occupants collided with their hard organ. In these collisions, the second is the most dangerous for occupant without seatbelt especially during pregnancy (RACE 2006). Occupants who are not wearing seatbelts will be projected, hitting the interior object of the vehicle or the pavement if the body was ejected outside of the vehicle. Meanwhile those who wear seatbelts are still attached to their seats as the seatbelts reduce the speed of the occupants. Most women misleadingly believe in fear that seatbelts would apply excessive pressure against the abdomen during car collision that may injure the foetus or even causes a subsequent miscarriage. Nevertheless, there is no scientific evidence to support this. Instead, many researchers had reported injuries suffered by pregnant women or their foetuses when they are not buckled up in the event of crash. Sections 3.1 and 3.2 will discuss more on the injuries.

3.1 Mother-To-Be Injury and Mortality

Crosby and Costiloe (1971) reported that the most common cause of foetal death in vehicle crash is the death of the pregnant victim. The foetus remains at risk if the pregnant woman suffers injuries or dies. Henry et al. from Renault group (1984) had evaluated the effectiveness of seatbelts on 49 pregnant occupants involved in road crashes. They found that none of the pregnant occupants who were properly belted suffered serious injuries. Four unbelted occupants were seriously injured and three occupants not using seatbelt loss their foetus. In the in-depth study of car crashes in California done by Agran et al. (1986), of nine cases involving pregnant women who died, three were found not using a seatbelt. Agran et al. (1986) reported that most of the victims were drivers and apparently most of the injuries were caused by the impact against the steering wheel during collision.

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Furthermore, Klinich et al. (1998) reported that there were nine cases in his study involving maternal death which resulted in foetal death. Only one victim was found properly belted. The other eight women were unbelted. In another study, unbelted pregnant drivers involved in frontal crashes during their last trimester will experience direct loading to the uterus by the steering wheel. This study mirrors Klinich’s study (1999) where he found that after the sixth month of pregnancy, the uterus lies below the steering wheel rim. Thus, it is clear that the primary way to protect the foetus is to protect the mother, and the way to protect the mother in car crash or to minimise the injury is by using the seatbelt.

In addition, injuries sustained by pregnant women have also been identified in several crash related studies. Pregnant women who were involved in crashes may experience placental abruption, uterine rupture, or emergency premature delivery. Placental separation or in medical terms, abruption placentae (AP), is stated as the leading cause of foetal loss in motor-vehicle crashes if the pregnant victim survived (Crosby and Costiloe 1971; Pearlman et al. 1990). Placental abruption occurs when the placenta separates from the uterus and disrupts the flow of oxygen and nutrients to the foetus. It is caused by crash forces transmitted to a woman’s belly when the seatbelt is worn improperly across the pregnant woman’s abdomen. These are the types of injuries that were reportedly sustained by mothers-to-be during crashes or immediately after a crash. Internal injuries to the chest, abdomen and uterus were also common.

In 1998, Klinich et al. had studied the injuries among pregnant occupants in road crashes in Michigan. They found out that unbelted pregnant occupants had reported to suffer a greater number of injuries and also, the severity was higher. Figure 1 shows that only about 5% unbelted pregnant women were safe from any injuries from traffic collision in the Klinich study. Most of the injuries occurred among the unbelted occupants. Thus, it is proven that seatbelt could save the life of pregnant women as well as the unborn baby.

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Figure 1 Distribution of type of injuries by restraint use (Klinich et al., 1998)

The use of a three-point belt needs to be emphasised. Wiechel et al. (1989) suggested that pregnant occupants should use three-point belts in order to give better protection than the lap belt alone. The combination of shoulder and lap belt is more effective in a frontal crash because it gives more protection for the thorax. When King et al. (1971) performed a series of test on 24 pregnant baboons, the result showed that total death for lap belts was 50% compared to 8.3% for three-point belts.

Furthermore, the foetus can also be injured when the pregnant woman made contact with the steering wheel or dashboard or when the pregnant woman’s abdomen was directly and abruptly hit by airbags. The long term effects on the unborn baby are also important and should be considered in an in-depth study of motor vehicle crashes. Several papers have discussed the adverse pregnancy outcomes related to motor-vehicle crashes. Adverse possible outcomes include low birth weight, neonatal respiratory distress syndrome, and foetal asphyxia leading to long-term physical or neurological problems for the child (Klinich et al. 2008).

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Figure 2 Distribution of traumatic injury mechanism, Pennsylvania (Weiss 2001)

3.2 Foetal Injury and Mortality

Traumatic injury-related foetal mortality has been widely studied and most of the studies agreed that traffic collision is the major cause of foetal mortality. In Pennsylvania, Weiss (2001) found that over 80% of the cases are due to traffic accidents. Thus, motor vehicle crashes are the fundamental cause of foetal trauma injury-related deaths (Weiss 2001). The figure 2 illustrates the percentage distribution of injury mechanism of foetal mortality.

Nevertheless, Weiss did not carry out an in-depth study of motor-vehicle crashes. Thus, his report lacked data on use of seatbelts during crashes.

Hyde et al. (2003) had undertaken a study comparing pregnant women involved in crashes with those not involved in crashes to study the effects of seatbelt use in reducing the occurrence of adverse foetal outcomes. Hyde and her colleagues found that of the 2.8% of pregnant women involved in crashes, unbelted pregnant women were 2.8 times more likely to be exposed to a foetal death, 1.3 times more likely to experience low birth weight infants and twice as likely to experience excessive maternal bleeding. However, there was no significant difference between belted pregnant women involved in crashes experiencing adverse foetal outcomes and women not involved in crashes during pregnancy (Hyde et al. 2003). Moreover, Hyde illustrated that unbelted mothers-to-be were much more likely to lose their foetus in a crash.

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Klinich et al. (2008) carried out an in-depth study on 57 pregnant women who had been involved in crashes to determine factors contributing to adverse foetal outcomes. It was generally known that severe crash and severe maternal injury led to a high risk of adverse foetal outcomes. Using Chi-square analysis and regression models, they found that adverse pregnancy outcomes were worsened by improper wearing of seatbelts by pregnant occupants during a crash. His findings showed that unrestrained occupants are less likely to have acceptable foetal outcomes and more likely to experience major complications associated with crash severity. According to Klinich et al. (2008), there was an 84% reduction in risk of experiencing adverse foetal outcomes when a pregnant woman uses a seatbelt properly. As can be seen, the improper use of the seatbelt could result in death of the unborn infant. This study also suggested that the use of a restraint during driving protects not only the mother but also the foetus as well as reduces the severity of maternal injury.

The findings of the study by Klinich et al. (2008) are aligned with the previous study of Pearlman et al. (1990). He reported that “62% of mothers who were not using the seatbelt properly or were unrestrained during a crash experienced adverse foetal outcomes while only 27% of mothers who had their seatbelt fastened properly were exposed to adverse foetal outcomes.” However, as the sample for the study by Pearlman et al. (1990) was just 42 cases, it caused the percentage to be rather high.

Figure 3 illustrates a prediction model developed by the Virginia Tech group based on combining their previous biomechanical studies with a sample of ‘real world pregnancy-related crashes’ and comparing those to adverse foetal outcomes data from the University of Michigan Transportation Research Institute (UMTRI) (Moorcroft et al. 2003). They analysed their data according to the type of restraints relative to speed of the crash. They found that non seatbelt users had a greater risk of experiencing adverse foetal outcomes after the crash.

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Figure 3 Effect of crash factors on risk of fatal loss (Moorcroft et al. 2003)

4.0 Anthropometric of Pregnant Women

Various studies had discussed the mechanisms of injuries during a crash and most authors reported on two significant elements. The first is the lap strap of the seatbelt and the second is the steering wheel (Klinich et al. 1998; RACE 2006; Pearlman et al. 1990). Many pregnant women complained that the lap strap seatbelt often shifted up over their abdomen even when worn properly. The second element is the steering wheel problem which may appear only to pregnant women driver but not the front or rear passenger. The distance between the pregnant woman’s abdomen and the steering wheel may shorten by gestational age (RACE 2006). They would have to push their seat back, but this would prevent them from operating the brake, clutch and steering wheel comfortably. These problems are more obvious among Asian women with smaller stature especially Malaysian women.

Hitosugi et al. (2007) carried out an anthropometric study between pregnant and non pregnant women. Hitosugi reported the horizontal clearance in pregnant women was significantly less than non pregnant women owing to protrusion of the abdomen. In crash testing using an adjusted dummy

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mimicking a pregnant woman’s weight showed that the forward displacement of pelvis distance is lesser for a pregnant subject when the seatbelt is worn. Thus, contact between a mother’s abdomen with the steering wheel in a frontal collision could be avoided by proper buckling of the seatbelt (Hitosugi 2007). Moreover, use of seatbelt will keep pregnant women as far away as possible from the steering wheel.

Most of the anthropometric studies had focused on front seat pregnant occupants but less on the rear pregnant passengers. Even the rear seat occupants do not have the advantages of the advanced safety features that front-seat occupants have, however it does not necessarily mean they are less safe. Since frontal collision are the most common type of crash, rear seat passengers in general have less of a risk of injury during a frontal collision because they are more likely to be further away from the initial point of impact. However, in the event of a collision, the safety of rear seat passenger also depends on their age and size, the type of vehicle and severity of the crashes.

5.0 Crash Simulation Model of The Pregnant Women Occupant

There are primarily two types of crash simulation. The first is computer simulation using computer model, and the second is physical simulation; using crash test dummy in real crash test. For the computer simulation, Duma et al. (2005) had developed a finite element model for small pregnant female using MADYMO to determine the risk of foetal injury between peak strains at the uterus and placental interface. The 30-week pregnant model consists of uterus, placenta and amniotic fluid in the abdomen. The model was restrained by a three-point seatbelt and was placed in the front seat passenger configuration; thus, it is apparent that steering wheel contact with the model’s abdomen during crashes could not be simulated. As a result, Duma suggested, in order to predict injury to uterine-placental interface and risk of foetal injury, the best practice is to measure abdominal loading at the uppermost uterine location of pregnant model. Figure 4 shows the seat configuration of the simulation model in front seat passenger side.

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Figure 4 Simulation configuration of 30 weeks pregnant woman model with three-point belt (Duma et al. 2005)

Figure 5 Side view of 3D model integrated with 39 weeks uterus (Delotte 2006)

On the other hand, Delotte (2006) developed a 3D virtual pregnant model in the driving position. MRI images of uterus from 50th Percentile European pregnant cadaver had been reconstructed and integrated into existed 3D male human model; Humos (Serre 2002). In Delotte’s model as shown in Figure 5, the simulation of impact between the pregnant stomach and steering wheel could be carried out. Futhermore, future alternative protection systems for pregnant occupant safety in car crash could be evaluated However, the drawback was that the male stature is bigger than female body frame and this will affect the performance of the 3D model.

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The first pregnant woman dummy was developed by Pearlman and colleagues in University of Michigan. A ‘pregnancy insert’ (Pearlman 1996) which consisted of uterus, amniotic fluid and 50th percentile foetus in the 28th gestational week was then inserted into the Hybrid III 50th percentile female dummy. The pregnant dummy enabled the study to capture foetal head injuries and acceleration data on a sled crash test. Subsequently, Pearlman (2000) continued to develop the Maternal Anthropomorphic Measurement Apparatus 2b (MAMA2b) to evaluate the probability of foetal loss due to placental abruption injury. This dummy was more accurate in terms of anthropometry to improve geometric interaction between the abdomen and seat restraint.

More recently, Delotte et al. (2008) carried out crash tests using post mortem cadaver. A gravid uterus was inserted into the abdomen of the cadaver and then, a 20 km/h frontal impact crash tests were carried out. Delotte found out that there was another interior part of the car that could possibly cause injury to pregnant women in crash, other than the lap belt–the backrest of the car seat.Delotte observed 2 kinematic events, lap belt loading at the beginning of the impact followed by back rest impact which suprisingly revealed the highest level of feotal movement (Dellote J.(2008). However, the cadaver used in this study was not a pregnant woman’s cadaver and this might possibly affect the behaviour of the abdominal wall. Yet, cadaver model is more biofidelic than a dummy model thus; making it more representative of human characteristics and behaviour in injury mechanism studies.

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6.0 Traffic Legislations

Exemptions:

The European Directive 91/671/EEC of 1991 indicated that member states may grant exemptions of seatbelt use to those related to specific physical conditions or individual circumstances and provide the competent authorities with an exemption certificate of a limited duration.

Weiss et al. (2006) reported that from the international survey of seatbelt use exemptions, six countries grant exemptions for pregnant women vehicle occupants. They are: Spain, Greece, Iran, Italy, Japan and Poland. All of these countries exempt pregnant women provided they have a medical certificate.

• [UK] The Ministry of Transport stated that there is no automatic exemption for pregnant women not to use seatbelts. The pregnant women need to have a doctor’s approval.• [JAPAN] Pregnant women are exempted from the current seatbelt use in Japan despite the fact that seatbelt use is essential to reduce the risk of fatalities for these women and their foetuses in car crashes (Ministry of Land, Infrastructure and Transport Japan). • [SPAIN] General Traffic Regulation of 1992, Section 119 stated that pregnant women are exempt from the use of seatbelts “when they have a doctor’s certificate in which their situation or condition as a pregnant women and date of birth are indicated”.

However, if legislative exemptions are given, there is the possibility that this might lead to lower seatbelt use after pregnancy.

Non-Exemption:

NHTSA recommends that pregnant women use their seatbelts. There are no specific rules that explain why pregnant women should not use their seatbelts unless recommended by a doctor.

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Malaysia:

The Malaysia Road Act 133 Part II Section 66 does not offer anything on seatbelt use by pregnant women. Thus it is suggested that pregnant occupant in Malaysia use their seatbealt properly to avoid injury unless their doctor

7.0 Recommendations

Using a seatbelt could potentially lower the risk for pregnant women and their unborn child. It is therefore recommended that a pregnant woman uses the seatbelt whenever she is in a car, while driving or occupying the front seat or even the rear seat. At present, there is no concrete scientific evidence to suggest that a belted pregnant woman will experience adverse foetal outcomes if involved in a crash. Thus, there is no reason for her not to buckle up using the existing seatbelt. The following is an effective guide for buckling up for pregnant women:

1. Always wear the three-point seatbelt (both lap portion and shoulder strap seatbelt) whenever in the car.

2. Wear the three-point seatbelt properly:

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Figure 6 Correct way to use a seatbelt (April Reign 2008)

a. Place the diagonal strap between breasts, moving the strap around the side of the abdomen (Figure 6).

b. Make sure the lap portion of the seatbelt strap sits comfortably under the abdomen.

c. Make sure there is a significant gap between the mother’s abdomen and steering wheel.

d. Sit as far away from the front airbags as you can; move the seat backward as much as possible. (Please refer to MIROS’ broucher released in November 2008 entitled "Say yes to seatbelts even if you are pregnant" for details)

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Figure 7 A pregnant woman uses seatbelt

In addition, if pregnant women are involved in an accident, the emergency personnel or doctor should be informed immediately so that the condition of the foetus can be evaluated. Furthermore, pre-natal care provider (doctor) can help promote seatbelt use during pre-natal visits. Pregnant women are also recommended to use three-point belts at anytime in the vehicle, therefore the middle rear seat of many Malaysian cars which equipped with lap belt is not advisable for pregnant woman. Thus, based on this review, pregnant women are now left with left or right rear passenger seat to choose from.

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8.0 Conclusions

Many studies had made it very clear that pregnant women should buckle up every single time they are in a vehicle. It is obviously proven that seatbelts protect the foetus. As a driver, pregnant women should follow the NHTSA guidelines. This is again to ensure their safety and the foetus. Acar et al. (2003) revealed that only 13% of pregnant women actually had the seatbelt correctly positioned according to safety guidelines. The writer believes that the situation in Malaysia will be worse. This is due to the lack of information and knowledge among pregnant women in Malaysia.

Whether the pregnant woman is driving or not is not an issue. Pregnant women can also be involved in crash even if they are not driving. There is a gap of in-depth study that discusses the position for pregnant women in a car if they are not the one driving. The writer believes that the rear seat is safer, but not the one in the middle. This is because most Malaysian cars will only be equipped with lap belt (two-point-belt) for the middle rear passenger. There is no regulation requiring a car to be fitted with a three-point belt for the middle rear seat in Malaysia. However, soon to be adopted United Nations Economic Commission for Europe (UNECE) Regulation No 16

1 will make it compulsory for the rear seat

to be equipped with three-point belt. As discussed, fatality risks of pregnant women and their foetus is higher when using the lap belts.

Recently, the global studies on pregnant women has lessened. Even if there is new intervention of anthropometric testing devices such as MAMA 2B, the study doesn't attract many researchers as it is not statistically significant. It is also influenced by the difficulty of getting data on pregnant women as the population is small, and the statistical number involved in a crash is lesser. The trends today are focusing on perfectness of restraint system occupant protections. They are aiming for 100% life saving in a collision. The challenge to protect the foetus is not of priority at the moment.

Many leading car manufacturers i.e. BMW, Volkswagen, Volvo and Mercedes do not highlight anything on the safety of pregnant women in their cars. The writer had hoped that the present drive to make cars safer would provide

1 UNECE R16: Safety-belts and restraint systems

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more information regarding seatbelts for pregnant women. Unfortunately, to the best of author’s knowledge, there is none. The author believes that the car manufacturers have taken certain consideration in improving pregnant women protection. However, there is a legal implication if the device failed in protecting the mother-to-be and the foetus.

None of the papers reviewed in this literature indicate any study on the medical fitness of pregnant drivers. It is important to highlight that if the driver is not medically fit, they shouldn't drive at all. This will reduce crash possibility on the roads.

As a conclusion from this review, it is suggested that pregnant women do not get exemptions from seatbelt use in a vehicle. In fact, they should be counselled to use seatbelts throughout pregnancy to reduce crash risk to themselves and the foetus.

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References

Acar, BS & Weekes, AM (2003), Pregnant driver behavior and safety, First International Conference on Driver Behavior and Training, Volume 1.

Acar, BS & Weekes, AM (2004), Designing for safety during pregnancy through a system for automotive engineers, International Journal of Crashworthiness, 9(6): 625–631.

Agran, PF, Dunkle, DE, Winn DG & Kent, D (1986), Fetal death in motor vehicle collisions, 30th Annual AAAM Proceedings: 285–294.

American Medical Association Committee (1972), Medical aspects of automobile safety during pregnancy, JAMA 221: 20.

American College of Obstetricians and Gynaecologists (ACOG) (1992), Automobile passenger restraints for children and pregnant women, International Journal of Obstetricians and Gynaecologists, 37: 305–308.

April Reign (2008), Saving lives..creating criminals? Accessed on 16 September, 2008, from www.breadnroses.ca/birthpangs.

Crosby, WM & Costiloe, JP (1971), Safety of lap–belt restraint for pregnant victims of automobile collisions, New England Journal of Medicine, 284(12):632–636.

Delotte, J, Behr, M, Thollon, L, Arnoux, P, Baque, P, Bongain, A & Brunet, C (2008), Pregnant woman and road safety: experimental crash test with post mortem human subject, Surgical and Radiologic Anatomy, 30(3).

Delotte, J, Behr, M, Baque, P, Bourgeon, A, Peretti, F & Brunet, C (2006), Modeling the pregnant woman in driving position, Surgical and Radiologic Anatomy, 28: 359–363.

Duma, SM, Moorcroft, DM, Stitzel, JD & Duma, GG (2005), A computational model of the pregnant occupant: local uterine compression effects the risk of fetal injury, ISB XXth Congress – ASB 29th Annual Meeting, July 31 –

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August 5, 2005, Cleveland, Ohio.

Hartemann, F, Henry, C, Faverjon, G, Tarriere, C, Got, C & Patel, A (1984), Ten years of safety due to the three-point seatbelt. Advances in belt restraint systems: design, performance, and usage, SAE Paper No. 840193:7–13.

Hitosugi, M, Kido, M, Maegawa, M, Nagai, T & Tokudome, S (2007), The benefits of seatbelt use in pregnant women drivers, Forensic Science International, 169: 247–275.

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Designed by: Publication Unit, Miros

MRev 02/2009

MIROS Review Report


Review on Safety of Pregnant OccupantTravelling With or Without

Restrant in a Passenger Vehicle


Malaysian Institute of Road Safety Research Lot 125-135, Jalan TKS 1, Taman Kajang Sentral43000 Kajang, Selangor Darul EhsanTel +603 8924 9200 Fax +603 8733 2005Website www.miros.gov.my Email [email protected]


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Review on Safety of Pregnant Occupant Travelling With or Without