The use of seatbelts in motor vehicles among pregnant women can reduce morbidity and mortality due to road traffic crashes; however, to date, there are no published studies on seatbelt usage among pregnant women in Indonesia. This research aims to promote the safety of pregnant women when using a motor vehicle. Its objective was to investigate the practices of seatbelt usage among pregnant front passengers and the associated factors.

A cross-sectional study was conducted in Samarinda, Indonesia. Pregnant women were asked to complete a self-administered validated and published questionnaire, the SaPeIH-Q, which included sociodemographic information, and an assessment of knowledge, attitudes, and practices related to seatbelt usage among pregnant women. Multiple logistic regression (MLogR) was performed via SPSS version 27 to identify independent factors associated with seatbelt usage.

Among the 326 pregnant front passengers, only 34.7% used seatbelts, and only 39.3% correctly identified the placement of the three-point seatbelt. The practice of using seatbelts before pregnancy and knowledge of seatbelt usage were significantly associated with using seatbelts during pregnancy (p = 0.001 and 0.004, respectively).

The seatbelt usage rate among pregnant front passengers was low. Pregnant front passengers who used seatbelts before pregnancy were more likely to use them during pregnancy, and pregnant women with good knowledge were more likely to use seatbelts during pregnancy. The rate of seatbelt use during pregnancy may improve with increasing knowledge of seatbelt usage and the use of seatbelts before pregnancy.

One of the indirect causes of maternal mortality and morbidity among pregnant women is road traffic crashes [1]. The other complications encountered after road traffic crashes include labour, premature labour, premature rupture of membranes (PROM), caesarean section, fetal death, and intrauterine bleeding [2].

Among the efforts made to reduce morbidity and mortality due to road traffic crashes was the introduction of three-point seatbelts. Seatbelts are designed with the aim of keeping the driver or passenger in their when braking suddenly or in the event of a collision [3]. The use of seatbelts is recommended, as it reduces fatal injuries from car crashes by half [4]. In Indonesia, the average annual rate of road fatalities has risen by 16.6% [5]. Alarmingly, according to observational data, from 2003 to 2007, all the fatalities resulting from crashes involving at least four-wheeled vehicles on the Semarang Toll Road, were those who did not wear seatbelts [6].

The compliance rate with three-point seatbelts among pregnant women traveling via motorized vehicles varies across countries. In countries where there was legislation making seat belt usage compulsory, such as Sweden, the United Kingdom, and Thailand, the rates were 98%, 74%, and 94%, respectively [7,8,9]. In areas where pregnant women were exempted from the legislation, such as Malaysia and Japan, the compliance rate was 43% and 38% respectively [10, 11].

In addition, the rate of correct usage of seatbelts also varies worldwide, such as, in Malaysia was 25% [10]. Iran (18%) [12], the United Kingdom (48%) [13], Sweden (61%) [14], United States of America (83%) [15] and Thailand (91%) [9].

To the best of our knowledge, no studies have investigated the use of seatbelts among pregnant women in Indonesia. Rear seatbelts have not been widely used in Samarinda in general. Furthermore, most pregnant women are passengers when travelling via car transportation. We aimed to promote the safety of pregnant women when using a motor vehicle. To achieve this, the present study was conducted. The objectives of this study were to investigate the practices of belt usage among pregnant front passengers and to identify the correlates that influence them. In our study, the front passenger is defined as the passenger who was not the driver; and occupied the seat next to the driver in a moving four-wheel vehicle.

This study's objectives were to investigate the practices of seatbelt usage among pregnant front passengers and to identify the correlates that influence them.

This was a cross-sectional study conducted at six obstetric clinics selected randomly from 33 obstetric clinics across six areas in Samarinda, Indonesia. Data collection was conducted from September 14th to November 30th, 2022. The total number of pregnant women who visited these clinics within one month was 3150. All pregnant women who visited these clinics travelled in cars as passengers, and were able to read and write in the Indonesian language were invited to participate.

The sample size was calculated via Epi Info (version 3) on the basis that the prevalence of pregnant women with knowledge of correct seatbelt use in pregnancy was 25% [10]; the attitudes of pregnant women who used seatbelts correctly were 79.8% [12], and the practice using the correct seatbelt in pregnancy was 69.4% [16]. Using a confidence interval (CI) of 95% and a margin of error of 5%, the minimum sample sizes calculated were 265, 296, and 230, respectively. Hence, the highest number was chosen, and to anticipate dropouts, the sample size was increased by 10% [17]. The final sample size was 326.

The sampling method employed was convenient sampling. Pregnant women who came to the research site and met the inclusion criteria were invited to participate. Informed consent was obtained from each participant after they were provided with an explanation of the purpose and method of the research. In addition, they were informed regarding which data would be identified and what would we do with the results.

The SaPeIH-Q, which was short for “Sabuk Pengaman pada Ibu Hamil - Questionnaire”; (which translated to “Seatbelt for pregnant women - Questionnaire”) was the research tool used in this study [18]. It is a self-administered questionnaire in the Indonesian language that was developed by the research team and has four components (demographics, knowledge, attitudes, and practices) for assessing knowledge, attitudes, and practice of seatbelt usage among pregnant women. It was developed after a literature review was done and using the health belief model. Pictorial diagrams and questions were discussed and vetted by the research team. It is a valid and reliable questionnaire with Cronbach’s alpha values of 0.931, 0.956, and 0.911 for the knowledge, attitude, and practice domains; respectively [18]. It had not been translated nor validated in the English Language.

The pregnant women were asked to provide demographic data in the form of age, occupation, ethnicity, education, income, distance from home to the clinic, gestational age, history of receiving information and sources of information about seatbelts, etc. The knowledge component consisted of 10 items and used a Likert scale with three answer choices (wrong, doubtful, and true). The obligation to use seatbelts and their purpose, type, and ability to use three-point seatbelts correctly were also asked. The attitude component consists of 12 statements about the obligation to use seatbelts and their purpose, type, and ability to use three-point seatbelts correctly. The respondents were asked to answer on a five-point Likert scale (strongly disagree, disagree, doubtful, agree, and strongly agree). Finally, in the practice component, the pregnant women were asked about their practice of using seatbelts when they were drivers and front and rear passengers seated on a five-point Likert scale (never, rarely, doubtful, often, and always). They were also asked about the use of seatbelts before (recalled) and during pregnancy, as well as the reasons for using and not using them.

The knowledge and attitude categories were determined based on the Angoff cut-off point. The cut-off point for knowledge was 69.8%. Knowledge was categorized as either poor knowledge if it was less than 69.8% or good knowledge if it was greater than 69.8%. The Angoff cut-off point for attitude was 68.6%. Attitude was categorized as negative if the percentage of questions answered was less than 68.6% and positive if it was greater than 68.6%. The practice of seat belt usage was divided into two categories: never (never, rarely, and sometimes) and always (often and always) [18]. In this study, we used good knowledge and positive attitudes as references in logistic regression analysis.

The independent variables in this study consisted of demographic data (age, ethnicity, occupation, distance from home to the clinic, income, education, gestational age, history of receiving information on seatbelt usage), knowledge of seatbelt usage, attitudes toward seatbelt usage, and recalled practices of seatbelt usage before pregnancy. The dependent variable is the practice of seatbelt usage among pregnant front passengers during pregnancy.

All analyses were carried out via SPSS version 27, with a confidence level of 95% and a standard error of 5%, and the significance level was set at a p-value of 0.05. The factors associated with the practice of seatbelts during pregnancy were analysed using logistic regression analysis. After initial selection using simple logistic regression with a criterion of p ≤ 0.25, the eligible variables were analysed using multiple logistic regression (MLR) to identify the dominant variable(s) [19]. The MLR was done using the Enter or Forced Entry method, in which all independent variables were entered into the model simultaneously without selection based on statistical significance [20], A p-value < 0.05 is used as a statistical significance criterion [21]. Further, a multicollinearity analysis is carried out using the Tolerance and Variance Inflation Factor (VIF). If tolerance > 0.2, then multicollinearity is not a serious problem, while if VIF < 5, then multicollinearity is low, not a problem; if 5 ≤ VIF < 10, then multicollinearity is moderate and needs to be watched out for, and if VIF ≥ 10, then multicollinearity is high, and the regression model can experience serious problems [22]. In this study, the Hosmer-Lemeshow Goodness-of-Fit Test was used to assess the suitability of the regression model to the data. The model is considered fit if the p-value > 0.05 [23].

Ethical approval was received from the Health Research Ethics Committee of the Health Polytechnic of East Kalimantan, Indonesia (LB.01.01/7.1/005630/2021).

A total of 326 pregnant women participated in this study. The demographic characteristics of the participants are shown in Table 1.

Pregnant women had good and poor knowledge, in192 (58.9%) and 134 (41.1%) women, respectively. Furthermore, 135 (41.7%) and 190 (58.3%) had positive and negative attitudes, respectively. One of the questions in the knowledge domain of the SaPeIH-Q was to identify the correct placement of the three-point seatbelt; in which only 128 (39.3%) pregnant women were able to identify this correctly. Further, only 123 (37.7%) pregnant women knew that there was a law indicating that seatbelt wearing was compulsory.

Among the 326 pregnant front passengers, more than half (174 (53.4%) always used seatbelts, whereas 152 (46.6%) never used seatbelts before they became pregnant. During pregnancy, only 73 (22.4%) always used seatbelts, whereas 253 (77.6%) never used them. The reasons given for not using seatbelts during pregnancy were short journey time in 144 (56.9%), feeling uncomfortable in 138 (54.5%), being afraid of endangering their fetuses in 44 (17.4%), not wearing seatbelts in 26 (10.3%), making them nauseous in 7 (2.8%), and causing shortness of breath in 3 (1.2%).

Based on simple logistic regression analysis, nine independent variables (occupation, distance from home to clinic < 1 km, distance from home to clinic > 2 km, gestational age in the first trimester and third semester, history of receiving information on seatbelt usage, practice of seatbelt usage among pregnant front passengers before pregnancy, and knowledge and attitudes toward seatbelt usage) were included in the multiple logistic regression analysis (p value ≤ 0.25). Further details are presented in Table 2.

Based on the results of simple logistic regression analysis, nine variables have a p-value ≤ 0.25. These nine variables were then analysed using multiple logistic regression via the enter method to see their simultaneous association with the practice of seatbelt use in pregnant front seat passengers. The analysis showed that only two variables were significantly associated with the practice of using seatbelts in pregnant front passengers (p < 0.05); which were the practice of using seatbelts before pregnancy and knowledge of seat belt use; as shown in Table 3.

These two variables were further analysed using multiple logistic regression, and the results of the final analysis can be found in Table 4. Two variables (the practice of seatbelt usage among pregnant front passengers before pregnancy and the knowledge of seatbelt usage among pregnant women) were found to be significantly (p < 0.05) related to pregnant front passengers’ usage of seatbelts in the final multiple logistic regression analysis. Pregnant front passengers who used seatbelts before pregnancy were 2.737 times more likely to practice during pregnancy. Pregnant women who had good knowledge were 2.277 times more likely to practice during pregnancy. The Hosmer-Lemeshow value produces p = 0.365, more than 0.05, meaning that there is a match between the observed data and the regression model.

The practice of seat belt usage before pregnancy and the knowledge of seatbelt usage among pregnant women, which were significantly associated with the practice of seatbelt usage among pregnant front passengers during pregnancy, showed no multicollinearity as the tolerance value > 0.2 and the variance inflation factor (VIF) value < 5, namely 0.906 and 1.103, respectively.

Our study revealed that the majority (77.6%) of pregnant front passengers did not use seatbelts while travelling via car transportation during pregnancy. This finding differs from several previous studies that reported a high percentage of seatbelt use among front passengers during pregnancy, ranging from 80.9 to 98% [11, 13]. Some of the factors associated with noncompliance include maternal physical changes, maternal education levels, lack of knowledge, and the acquisition of prior information about seatbelt usage.

We found that the practice of seatbelt usage among pregnant front passengers during pregnancy was significantly associated with knowledge of seatbelt usage; pregnant women who had good knowledge were two times more likely to use seatbelt during pregnancy. The finding is like previous studies, it was shown that by acquiring knowledge about seatbelt usage, one would be more likely to practice [24]. In addition, seatbelt ignorance was the reason for the decrease in adherence to their use [25].

Pregnant women who know the benefits of using a seatbelt during pregnancy tend to use a seatbelt during their pregnancy [11]. Thus, having poor knowledge of seatbelt usage leads to ignorance of the benefits of seatbelt usage. We found that pregnant women who did not wear seatbelts provided many reasons, such as feeling uncomfortable, making them nauseous, and causing shortness of breath. Pregnant women persevere if there are few troubles, such as the above if they know it is for the safety of their unborn child and themselves. Furthermore, poor knowledge may lead pregnant women to believe that wearing seatbelts during pregnancy may do more harm than good to their unborn babies [24, 25]. Pregnant women have a strong sense of a protective nature toward their unborn fetus; thus, this, not surprisingly, will consequently lead to noncompliance. This was also found in our study, as some of the women did not wear seatbelts because they were afraid of endangering their fetuses.

In Indonesia, specific locally produced guidelines related to driving safety, including the use of seatbelts for pregnant women, are not available. In countries where this information is available, the knowledge is better, and the compliance rate is higher [15, 16, 24, 26, 27]. In the United States of America, for example, the American College of Obstetricians and Gynaecologists (ACOG), together with the National Highway Traffic Safety Administration (NHTSA) and the American Medical Association, recommended and emphasized the importance of seatbelt use during pregnancy by providing information on how to use seatbelts correctly, thus avoiding discomfort or injury due to the use of seatbelts among pregnant women [28, 29]. In addition, in Indonesia, material concerning the importance of using seatbelts during pregnancy has not been included in the maternal and child health book published by the Ministry of Health of the Republic of Indonesia [30]. This may lead to the perception that the seatbelt issue is not important.

We also found that pregnant women rarely received information regarding seatbelt usage during pregnancy from healthcare professionals but received information elsewhere, namely, internet, radio, friends, and family. The accuracy of the information from these sources cannot guarantee their validity. Therefore, incorrect information may be relayed about seatbelt use during pregnancy, which may pose a great risk to pregnant women, resulting in incorrect usage of the seatbelt and/or non-compliance. Alarmingly, we found that only 39% of pregnant women could correctly identify the position of the seatbelt when it was used during pregnancy. This may mean that more than half of the women could use seatbelts incorrectly when travelling via car transportation, which increases the risk of harming themselves and their unborn fetuses. Incorrect placement of seatbelts has been found previously to cause complications such as placental abruption, uterine rupture, preterm birth, low birth weight, infant respiratory distress syndrome, maternal shock, polytrauma, and longer hospital stays. In addition, it was found that in those who had premature birth as a result of RTA, there was an increased risk of cerebral palsy [31].

Therefore, pregnant women must receive education about seatbelts during pregnancy during their antenatal period. Previously, increased information on the correct method of wearing seatbelts during pregnancy was reported resulting in an increase in the prevalence of seatbelt usage among pregnant women [32]. Furthermore, providing educational leaflets to pregnant women has led to a marked increase in knowledge and compliance with the use of seatbelts during pregnancy among pregnant women [33]. In addition, verbal information given by healthcare providers can lead to an improvement in the compliance rate [24, 27, 34]. Pregnant women who remember instructions on how to use seat belts correctly were found to be able to answer questions about the accurate placement of a three-point seatbelt [13]. Compared with those who do not receive information, pregnant women who have received information about the use of seatbelts also tend to be able to identify the correct use of seatbelts [27, 34,35,36]. A demonstration may also be needed to provide information to ensure correct and confident seatbelt use [36]. We found that most pregnant women preferred to have their source of information in the form of a video and via the Internet and social media. A video would allow a demonstration of the correct use of seatbelts without being physically present with the pregnant woman. Social media or the internet can make videos accessible at any time and any location. Hence, there is a need to develop educational modules in the form of videos that are widely accessible via the Internet and social media.

One of the known contributing factors to high rates of seatbelt noncompliance during pregnancy is the unavailability of national legislation, which makes seatbelt use during pregnancy compulsory [10]. In Japan, pregnant women are exempt from mandatory seatbelt laws, leading to a significant decline in seatbelt use as pregnancy progresses [11]. The rate of compliance improved in Japan after the introduction of compulsory belt legislation [37, 38]. Further, countries with available national legislation have achieved higher rates of compliance [13, 25, 36]. The United States mandates seatbelt use for all occupants, including pregnant women, and the degree of compliance with seatbelt usage among pregnant women is approximately 88%, which is comparable to that among nonpregnant women [39]. In Indonesia, however, the obligation to use seatbelts for drivers and front passengers for the general public, including pregnant women in Indonesia, was stipulated in Law No. 22 of 2009 concerning traffic and road transportation [40]. However, this did not favour the compliance rate of seatbelt use in our study. Why was the compliance rate still poor?

One of the reasons could be the lack of legal awareness among pregnant women, as we found that only 37.7% of pregnant women were aware of the availability of the law, as stipulated earlier. Thus, it is important to increase awareness among pregnant women. Public health campaigns through mass media have been shown to create awareness and encourage positive behavioural change [41]. In addition, enforcement campaigns have been shown to increase awareness of and compliance with legislation [42].

The enforcement of the law is crucial to promote compliance. The law was being enforced in Indonesia as the number of tickets/penalties issued by the police increased [43, 44]. However, infirm legal action or penalties do not provide a deterrent effect for lawbreakers. Legal actions or penalties that are considered light may cause people to ignore the law. In Indonesia, the penalty for not wearing seatbelts is Rp 250,000.00 (USD 15). This amount could otherwise buy a full tank (30 L) of subsidized petrol for a 1500 cc car. In comparison, the penalty for not wearing a seatbelt is up to £500 (Rp 9 million) and up to $50 (Rp. 813,000.00), in the UK and USA, respectively. Previously, it was reported that an increase in penalty levels is associated with an increase in seatbelt usage [45]. Local policymakers could explore this further and review the penalty to help increase the degree of compliance.

Furthermore, enforcement of the law would require considerable manpower and resources. During peak hours, when most of the roads are congested, the law enforcement officers on duty are found to give out warnings to offenders, as the procedure of giving out penalties would add to the chaos, as there would be a need to stop the vehicle for longer to give out tickets [44]. The introduction of areas with camera enforcement has helped identify traffic offenders; however, this approach is not widely available in Samarinda. In addition, more legal enforcement officers will be required on-site to correct seatbelt placement if the seatbelts are found incorrectly.

In addition to knowledge of seatbelt usage, the practice of seatbelt usage before pregnancy is also associated with the use of seatbelts during pregnancy. Pregnant women are almost three times more likely to wear seatbelts during pregnancy if they use seatbelts before they become pregnant. This finding is like those of previous studies [27, 35]. The habit of using seatbelts was developed because the women were accustomed to using seatbelts before pregnancy, strengthening their commitment to using them during their pregnancy as a protective measure [25, 46]. However, alarmingly, we found that only half of the pregnant women used seatbelts before pregnancy. It seems that seatbelt usage is not a normality among women in Samarinda. Families, husbands, or friends who always use seatbelts may influence increasing seatbelt use during pregnancy [24]. Therefore, to increase the compliance rate of seatbelt usage among pregnant women, the compliance rate of seatbelt usage among people in Samarinda in general should be improved, especially among women of reproductive age.

There are several limitations to our study. The data were obtained via self-administered questionnaires, and the practice of seatbelt usage was dependent on recall and was largely subjective. Our participants were mainly from clinics, so the results cannot be generalized to all of Indonesia.

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Conception and design, Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis), writing, review, and/or revision of the manuscript: IH, IAI, ZI, MSMR, and SD. Data collection: IH.

Correspondence to Suzanna Daud.

This research was conducted in compliance with the Helsinki Declaration. Ethical approval was received from the Health Research Ethics Committee of the Health Polytechnic of East Kalimantan, Indonesia (LB.01.01/7.1/005630/2021) in line with the principles stated in the Research Ethics Guidelines and Standards and National Health Development (PSEPPKN) that refer to World Health Organisation 2011 (Standards & Operational Guidance for Ethics Review of Health-Related Research with Human Participants) and CIOMS 2016 Standards. (Standards by the Research Ethics Commission and National Health Development). Each participant signed a consent form before admission to the study.

Consent to publish has been received from all participants.

Ida Hayati, Suzanna Daud, Zaliha Ismail and Ilham Ameera Ismail had filed for copyright # Sapeih-Q: Kuesioner Penggunaan Sabuk Pengaman Pada Ibu Hamil and certificate of notification CRLY2024M01549 was issued by the Intellectual Property Corporation of Malaysia (MyIPO).

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