Abstract
-
Objective
Trauma is one of the leading causes of obstetric morbidity and mortality, and incorrect seat belt use is a major determinant of adverse outcomes. This study evaluated the impact of structured education on proper seat belt use during pregnancy and examined preferences for future interventions.
-
Methods
This prospective pilot study was conducted at a single center in Korea, over an 8-week period. Pregnant women between 20 and 37 weeks of gestation who visited the outpatient obstetrics and gynecology department were enrolled. A pre-education survey assessed baseline seat belt practices. Participants then received structured education, and a post-education survey 1 month later evaluated changes in awareness and behavior.
-
Results
Sixty participants were included in the final analysis. Most reported obtaining seat belt information from unverified sources, particularly online communities. Many indicated a preference for structured education delivered by obstetricians, especially early in pregnancy. After the intervention, knowledge of proper seat belt use increased from 21.7% to 85.0% (P<0.001), and correct seat belt usage rose from 16.7% to 88.3% (P<0.001). Seat belt use while driving also improved markedly, increasing from 19.5% to 78.0% (P<0.001), demonstrating the program’s effectiveness in enhancing awareness and behavior.
-
Conclusion
Education on seat belt use during pregnancy significantly improved both knowledge and correct usage among pregnant women. Routine, formal educational programs are recommended to promote maternal and fetal safety.
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Keywords: Seat belts; Pregnant women; Health education; Accidents; Traffic; Maternal health
Capsule Summary
What is already known
Trauma is a major cause of maternal morbidity and mortality. Incorrect use of seat belts during pregnancy is a key determinant of adverse maternal and fetal outcomes. Despite recommendations, adherence to proper seat belt use during pregnancy remains low.
What is new in the current study
Structured education on proper seat belt use during pregnancy significantly improved both awareness and actual usage. Correct seat belt use increased from 16.7% to 88.3% after education, with substantial improvement in seat belt use while driving. Findings support the need for formal, routine educational interventions in maternity care to enhance maternal and fetal safety.
INTRODUCTION
Trauma is one of the most common causes of obstetric morbidity and mortality [
1–
3]. Motor vehicle accidents constitute one of the primary sources of trauma and are associated with adverse outcomes such as miscarriage, premature rupture of membranes, preterm delivery, and fetal demise [
4–
8]. Although several factors, including maternal age and gestational age, determine the risk of mortality and injury severity in vehicle collisions, appropriate use of three-point seat belts markedly reduces these risks, particularly those related to seat belt misuse [
9,
10]. Consequently, many countries have implemented laws mandating seat belt use for drivers and passengers alike [
11]. Multiple studies have shown that wearing a seat belt during pregnancy improves maternal and fetal outcomes after motor vehicle collisions compared with not wearing one [
12–
15].
However, incorrect utilization of seat belts remains a major determinant of unfavorable outcomes in motor vehicle accidents involving pregnant women [
16–
18]. Obstetric care providers therefore play a critical role in communicating the importance of proper seat belt use to all pregnant patients [
19–
21]. Despite this need, research shows that fewer than half of pregnant women receive counseling on correct seat belt usage during prenatal care [
22–
24]. Similarly, in Korea, there are no standardized methods, recommended timing, or designated institutions responsible for educating pregnant women about proper seat belt use. Although the Korea Disease Control and Prevention Agency (KDCA) offers informational leaflets, these materials are accessible only to individuals who proactively seek them.
A study conducted in Japan demonstrated that distributing instructional leaflets on seat belt use during pregnancy increased seat belt usage among pregnant women [
25]. Nonetheless, we recognized the need for a more comprehensive and systematic educational approach. Therefore, this study aimed to evaluate the effectiveness of providing education on proper seat belt placement for pregnant women. We conducted pre- and post-education surveys to assess changes in awareness and usage, and to explore preferences regarding the methods and timing of future seat belt education.
METHODS
Ethics statement
The study protocol was reviewed and approved by the Institutional Review Board of Samsung Medical Center (No. SMC 2022-10-004). Written informed consent was obtained from all participants prior to enrollment.
Study settings and participants
This prospective pilot study was conducted at the outpatient clinic of the Department of Obstetrics and Gynecology at Samsung Medical Center, between October 2022 and December 2022. Samsung Medical Center is a major tertiary care facility with approximately 70,000 patient visits annually. It was designated by the Korean Ministry of Health and Welfare as the first high-risk maternal and newborn intensive care center in Seoul, operating an 11-bed maternal-fetal intensive care unit and a 59-bed neonatal intensive care unit. As such, the hospital provides care for a substantial number of pregnant women with varying levels of obstetric risk. As this was a pilot study, a formal sample size calculation was not performed in advance, because there was insufficient prior evidence to estimate expected effect sizes or outcome variability.
Pregnant women visiting the outpatient clinic who consented to participate were recruited for the study. Exclusion criteria included a gestational age of 37 weeks or more, given the likelihood of delivery before the post-education survey; physical or mental conditions that prevented participation; and refusal to participate.
Study flow
Participants were recruited in the waiting area of the obstetrics outpatient clinic by an emergency medicine specialist and a research nurse with over 2 years of experience in the injury prevention division and training from the KDCA. After a detailed explanation of the study and confirmation of informed consent, participants received a 15-minute education session using a KDCA-produced leaflet. This educational leaflet, developed by the KDCA, provides guidance on the proper and safe way for pregnant women to wear a seat belt. It emphasizes that all pregnant women should wear a seat belt whenever traveling in a vehicle, ensuring that it fits correctly and remains snug against the body. It instructs that the shoulder belt should pass across the center of the shoulder and chest, while the lap belt should be positioned below the abdomen, across the pelvis, to minimize uterine pressure. Additional recommendations include maintaining at least 25 cm of distance between the sternum and the steering wheel, avoiding prolonged driving by taking breaks every hour and especially after 4 hours to reduce the risk of deep vein thrombosis, and keeping an upright posture with the seatback reclined no more than 110°. The leaflet also notes that placing a thin cloth or blanket beneath the belt may enhance comfort without compromising safety. Overall, the KDCA material aims to increase awareness and promote correct seat belt use among pregnant women to reduce trauma-related risks during vehicle travel. Practical demonstrations were also provided to illustrate proper belt positioning.
A pre-education survey was administered immediately before the educational session, and a follow-up post-education survey was distributed 1 month later via a mobile survey platform (
Suppl. 1).
The educational material consisted of an official leaflet provided by the KDCA (
Suppl. 2), which detailed the correct application of seat belts during pregnancy. Education sessions were conducted individually by an emergency medicine specialist and a researcher experienced in injury prevention education, both of whom participated in KDCA-hosted training sessions at least twice annually. Each session lasted approximately 15 minutes.
The pre- and post-education surveys used in this study were adapted and modified from the instrument developed by Morikawa et al. [
25] to ensure alignment with the objectives of our research. The pre-education survey collected demographic information (e.g., age, gestational age, driving habits) and included 13 questions assessing awareness of seat belt necessity and correct usage, prior exposure to education, sources of information, and reasons for noncompliance.
The post-education survey, administered 1 month after the educational session, included seven questions assessing awareness of the importance and correct application of seat belts during pregnancy, as well as adherence to seat belt use following the intervention. Additionally, it explored participants’ preferences regarding the optimal timing, personnel, location, and modality for future seat belt education.
Statistical analysis
Categorical variables were summarized as frequencies and percentages. The McNemar test was applied to evaluate changes in awareness and adherence to proper seat belt use before and after the educational intervention, assessing paired proportions to determine the significance of the intervention’s impact on participants’ behavior and awareness. A P-value of less than 0.05 was considered statistically significant. All statistical analyses were performed using R ver. 4.1.2 (R Foundation for Statistical Computing).
RESULTS
Participant characteristics
Of the 75 pregnant women initially recruited, 5 were excluded because they delivered before the post-education survey, and 10 did not respond to the post-education survey. Thus, 60 participants were included in the final analysis (
Fig. 1).
Table 1 summarizes their baseline characteristics. Participants ranged in age from 27 to 44 years, with the largest proportion between 31 and 35 years (n=26, 43.3%). Regarding gestational age, 10 participants (16.7%) were in the first trimester (≤13 weeks), 31 (51.7%) were in the second trimester (14–27 weeks), and 19 (31.7%) were in the third trimester (≥28 weeks).
Most participants were first-time mothers (n=48, 80.0%), followed by women with a parity of 2 (n=11, 18.3%) and one with a parity of 3 (n=1, 1.7%). The majority held a driver’s license (n=55, 91.7%), and nearly all reported using seat belts before pregnancy while driving (n=53, 96.4%) or as passengers (n=52, 94.5%). Regarding driving frequency, 10 participants (18.2%) drove daily, 17 (30.9%) drove more than once a week, 20 (36.4%) drove more than once a month, and 8 (14.5%) did not drive.
Awareness of seat belt use prior to education
The overall pre- and post-education survey results are presented in
Table 2. Before the educational intervention, only 13 participants (21.7%) reported being aware of the correct method of seat belt use during pregnancy. The most common source of information was online communities (n=4, 30.8%), followed by websites (n=3, 23.1%), parenting books (n=3, 23.1%), YouTube (n=2, 15.4%), and acquaintances (n=1, 7.7%). Notably, none of the participants received information from public health centers or hospitals (
Fig. 2).
Only 10 participants (16.7%) reported using seat belts correctly or using a maternity seat belt. Among these, six began using a maternity seat belt in the first trimester and two in the second trimester; none reported initiating use in the third trimester. Among the 50 participants who did not use seat belts correctly during pregnancy, the most common reason was a lack of knowledge about proper usage (n=28, 56.0%), followed by infrequent car rides (n=9, 18.0%) and the belief that seat belts were unnecessary (n=8, 16.0%).
Effect of education
One month after the educational intervention, the number of participants aware that pregnant women should wear seat belts increased from 57 (95.0%) to 60 (100%; P=0.248). Awareness of the correct method of seat belt use rose significantly from 13 (21.7%) to 51 (85.0%; P<0.001). Proper seat belt use or maternity seat belt use increased from 10 (16.7%) to 53 (88.3%; P<0.001). Satisfaction with the educational session was high; among the 60 respondents, 91.6% rated their satisfaction as 4 or 5 on a 5-point scale, indicating that most participants found the education helpful and relevant. The mean satisfaction score was 4.5±0.8 (
Fig. 3).
The most common reason for not wearing a maternity seat belt before the intervention—lack of knowledge of correct usage—remained the primary reason afterward, though the number citing this concern dropped substantially from 28 to 5. Pre-survey reasons such as infrequent car rides (n=9) and believing seat belts were unnecessary (n=8) decreased to 0 and 2 participants, respectively.
Among the 41 participants who drove after becoming pregnant, the proportion reporting seat belt use while driving increased from 8 (19.5%) to 32 (78.0%; P<0.001). Seat belt use while sitting in the passenger or back seat also increased, from 35 (58.3%) to 45 (75.0%), although this change was not statistically significant (P=0.078).
Opinions on future seat belt education
None of the participants had previously received formal education on seat belt use from official institutions or healthcare providers. Regarding preferences for future education, 36 participants (60.0%) indicated that the first trimester was the most appropriate time for education, while 20 participants (33.3%) preferred the prenatal period in general (
Fig. 4A).
In terms of preferred educational methods, most participants preferred receiving education at obstetric clinics (n=31, 51.7%), followed by official KDCA YouTube channels (n=16, 26.7%). Additional preferences included public health centers and the official KDCA website (
Fig. 4B).
DISCUSSION
This study demonstrated that although most participants recognized the importance of wearing seat belts during pregnancy, there remained a substantial gap in knowledge regarding proper seat belt positioning. Improper placement, such as positioning the lap belt over the abdomen rather than low across the hips and pelvis, increases the risk of placental abruption, uterine injury, fetal trauma, preterm birth, and fetal death in the event of a collision. Correct seat belt use reduces these risks [
9,
10]. The educational intervention effectively enhanced both awareness and correct seat belt application among pregnant women. Notably, none of the participants had previously received formal education on this topic, and only a small proportion had independently sought relevant information.
Pregnant women face a higher risk of traffic accidents and associated complications compared with the general population [
26]. The risk rises substantially during the second trimester, with studies reporting a 42% increase in accident rates relative to non-pregnant periods [
27]. This heightened risk is exacerbated when seat belts are not used [
28].
Due to physiological changes during pregnancy, correct seat belt use differs from that of the general population [
29]. The upper strap should cross over the shoulder and between the breasts, while the lower strap should be positioned beneath the abdomen. However, standard vehicle seat belts are designed for the general population, making correct placement difficult for pregnant women [
29]. To address this issue, specialized maternity seat belts have been developed to reposition the lower strap below the abdomen, allowing impact forces to be distributed across the shoulders and thighs during collisions, thereby reducing fetal risk. Despite the availability of these devices, our findings showed that most women were unaware of them, highlighting the importance of targeted education and promotion of such safety products.
Although some pregnant women reported awareness of the correct method of wearing seat belts, standardized education was uncommon. The absence of formal resources contributed to reliance on informal sources, including acquaintances and online communities, which may lead to the spread of inaccurate or incomplete information [
30]. This discrepancy between perceived awareness and actual proper practice underscores the need for comprehensive, structured education to safeguard both maternal and fetal health. Consistent with this, our survey indicated that most participants preferred receiving education before 13 weeks of pregnancy, ideally during routine obstetric clinic visits.
Pregnant women are particularly vulnerable to injuries from even minor accidents compared to the general population; however, awareness of this vulnerability remains limited. National-level attention and support for structured seat belt education programs tailored to pregnant women are therefore essential to prevent maternal and fetal injuries related to traffic accidents. Providing expectant mothers with accurate information and reinforcing its application can help promote safer behaviors and reduce risks associated with improper seat belt use during pregnancy.
Limitations
This study has several limitations. First, the investigation was conducted at a single center, which may limit the generalizability of the findings to broader populations. Second, the study relied on self-reported survey data, which may not fully reflect actual behaviors. Additionally, the study did not assess the direct impact of correct seat belt use on accident rates or injury severity. Future research should address these limitations by including larger and more diverse participant groups and by employing objective measures of seat belt usage.
Conclusions
Providing appropriate information significantly improves both understanding and practical application of correct seat belt use during pregnancy. More systematic and standardized education on this topic is essential and strongly recommended to enhance maternal and fetal safety.
NOTES
-
Author contributions
Conceptualization: TK, HY, MK; Data curation: TK, SH, SJM; Formal analysis: YRL, GTL, JEP; Investigation: TK, SH; Methodology: SUL, SJM, HY, WCC, GTL, HC, MK; Project administration: SJM, SH, WCC; Supervision: TK, SH, JEP; Validation: JEP, HC, HY; Visualization: HY, MK, TK; Writing–original draft: SYS, SH, HC; Writing–review & editing: all authors. All authors read and approved the final manuscript.
-
Conflicts of interest
Won Chul Cha is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.
-
Funding
This study was supported by the Korea Disease Control and Prevention Agency (KDCA).
-
Data availability
The data analyzed in this study are available from the corresponding author upon reasonable request.
Data sharing is not applicable as no new data were created or analyzed in this study.
SUPPLEMENTARY MATERIAL
Fig. 1.Flow diagram of participant enrollment.
Fig. 2.Previous methods of gathering information regarding seat belt use during pregnancy.
Fig. 3.Satisfaction ratings for educational material.
Fig. 4.Survey results on future education. (A) Preferred timing of education. (B) Preferred method of education. KDCA, Korea Disease Control and Prevention Agency.
Table 1.Baseline characteristics of participants (n=60)
Table 1.
|
Characteristic |
No. of participants (%) |
|
Age (yr) |
|
|
25–30 |
7 (11.7) |
|
31–35 |
26 (43.3) |
|
36–40 |
21 (35.0) |
|
41–44 |
6 (10.0) |
|
Pregnancy weeks |
|
|
≤13 |
10 (16.7) |
|
14–27 |
31 (51.7) |
|
≥28 |
19 (31.7) |
|
Parity |
|
|
First |
48 (80.0) |
|
Second |
11 (18.3) |
|
Third |
1 (1.7) |
|
Driver's license holder |
|
|
Yes |
55 (91.7) |
|
No |
5 (8.3) |
|
Frequency of driving (n=55)a)
|
|
|
Daily |
10 (18.2) |
|
More than once a week |
17 (30.9) |
|
More than once a month |
20 (36.4) |
|
No driving |
8 (14.5) |
|
Seat belt usage prior to pregnancy (n=55)a)
|
|
|
While driving |
53 (96.4) |
|
While sitting in passenger seat or back seat |
52 (94.5) |
Table 2.Pre- and post-education survey results (n=60)
Table 2.
|
Survey item |
No. of participants (%) |
P-value |
|
Pre-education (n=60) |
Post-education (n=60) |
|
|
Did you know that pregnant women also must wear seat belts? |
|
0.248 |
|
Yes |
57 (95.0) |
60 (100) |
|
|
No |
3 (5.0) |
0 (0) |
|
|
Do you know how to use a seat belt while pregnant? |
|
|
<0.001 |
|
Yes |
13 (21.7) |
51 (85.0) |
|
|
No |
47 (78.3) |
9 (15.0) |
|
|
Are you using a maternity seat belt? Or are you using your seat belt correctly? |
<0.001 |
|
Yes |
10 (16.7) |
53 (88.3) |
|
|
No |
50 (83.3) |
7 (11.7) |
|
|
(If answered "no") what is the reason for not using it? |
|
|
|
|
Because I thought it was unnecessary |
8 (16.0) |
2 (28.6) |
|
|
Because it is physically uncomfortable |
2 (4.0) |
0 (0) |
|
|
Because I don’t know how to wear it correctly |
28 (56.0) |
5 (71.4) |
|
|
Because I go on fewer car rides |
9 (18.0) |
0 (0) |
|
|
Othera)
|
3 (6.0) |
0 (0) |
|
|
During pregnancy, did you always wear your seat belt when driving? (n=41)b)
|
<0.001 |
|
Yes |
8 (19.5) |
32 (78.0) |
|
|
No |
33 (80.5) |
9 (22.0) |
|
|
During pregnancy, did you always wear your seat belt when sitting in the passenger seat or back seat? |
0.078 |
|
Yes |
35 (58.3) |
45 (75.0) |
|
|
No |
25 (41.7) |
15 (25.0) |
|
|
(If answered "no") what is the reason for not using it? |
|
|
|
|
Because I thought it was unnecessary |
6 (24.0) |
1 (6.7) |
|
|
Because it is physically uncomfortable |
2 (8.0) |
10 (66.7) |
|
|
Because I don’t know how to wear it |
8 (32.0) |
1 (6.7) |
|
|
Because I go on fewer car rides |
9 (36.0) |
3 (20.0) |
|
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, Sejin Heo1
