Restraint use and seating position among children in motor vehicles

Restraint use and seating position among children in motor vehicles
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SA Jou
Restraint use and seating position among children in motor vehicles in Bloemfontein
U M Hallbauer, MB BCh, MPraxMed, DCH, FCPaed (SA), MMed (Paed)
Department of Paediatrics and Child Health, University of the Free State, Bloemfontein
G Joubert, BA, MSc
Department of Biostatistics, University of the Free State, Bloemfontein
S F Ahmed, undergraduate MB ChB student
S Brett, undergraduate MB ChB student
P R Dawadi, undergraduate MB ChB student
J Kruger, undergraduate MB ChB student
Faculty of Health Sciences, University of the Free State
Corresponding author: U M Hallbauer ([email protected])
Background. Most child deaths from motor vehicle accidents (MVAs) occur in low- and middle-income countries. Effective measures to
protect children involved in MVAs include wearing age-appropriate child restraints and being seated in the rear of the vehicle.
Methods. A descriptive study was used to assess use of child restraints, seating positions of children, driver restraint and vehicle overloading
in Bloemfontein in 2007. Two pairs of observers stood at selected sites recording these findings. The study was done over a period of 1
Results. A total of 512 children in 374 vehicles were assessed. Just over a third of the children were seated on the front seat of the vehicle,
and 14.1% were seated on other people’s laps (73.6% of these were on the front seat). Restraints were used by 8.8% of children and 17.4% of
drivers; 10 times more children used restraints if the driver was restrained versus not restrained. Between 9.3% and 20.4% of vehicles were
assessed as being overloaded with passengers.
Conclusion. The safety of child passengers in Bloemfontein in the event of an MVA is threatened by poor adherence to basic safety
measures. Enforcement of correct seating position and use of child restraints will prevent unnecessary deaths, disabilities and suffering of
child passengers injured in the event of an MVA. Driver motivation and responsibility is important in achieving safer seating of children
in motor vehicles.
Motor vehicle accident (MVA) injuries are a leading cause of death
and disability in children in both developed and developing countries
and account for 22.3% of child injury deaths globally.1 Globally, more
than 85% of casualties and 96% of child deaths from road traffic
accidents occur in low- and middle-income countries. The road traffic
mortality rate in South Africa in 2000 was estimated to be 39.7/
100 000 population. This is double the global rate and 26% higher
than the aggregate figure for Africa.2-4 The overall injury-related
mortality burden in South Africa is between 11% and 13%. In this
category, transport-related injuries account for 33% of all deaths.5
Injuries from MVAs are the fourth leading cause of death in all age
groups in South Africa.2 In South Africa, being a child passenger in
a motor vehicle ranks fifth as a cause of death from injury.5 Reliable
data on MVA-related disability in children are sparse.
After the first collision in an accident, a second collision occurs
between the unbelted passenger or driver and the interior of the
vehicle. This is responsible for the majority of injuries and can be
prevented by seatbelts.6 Toddlers are particularly vulnerable to injury
because the mass of a young child’s head, in relation to its body,
causes the child to be hurled head first in collisions. The head absorbs
the impact when it strikes the dashboard or windscreen, resulting
in serious or fatal brain injuries. Children held on laps by a well-
meaning adult will be dislodged by the huge gravitational forces in
the case of an accident.
In a 50 km/hour collision, an unrestrained baby or child can be
thrown forward with a force 30 - 60 times its body weight and could
slam into the driver or front passenger. Child passengers who are
not secured in their back seats increase other passengers’ and the
driver’s risk of injury as they become a missile in an accident, with
devastating effect.7 Ejection from a vehicle as a result of an accident
usually results in death.
Effective measures to protect children include using age-appropriate
restraints and being seated in the rear of the vehicle.6 Safety belts are
the single most important life-saving device in a vehicle in the event
of an accident and can reduce death and hospitalisation rates by more
than 50%.7,8 Children under 1 year of age (body weight <9 kg) should
be secured in a child safety seat on the rear seat, facing the back of the
vehicle to reduce the risk of cervical spine injury. A proportionally
large head and weak neck predispose a young child to head and neck
injuries when placed in forward-facing child safety seats (‘Seat-belts
and child restraints: increasing use and optimising performance’,
European Transport Safety Council, 1996, quoted in World Report
on Road Traffic Injury Prevention1). Children aged between 1 and 6
SAJCH JULY 2011 VOL. 5 NO. 2
years (10 - 18 kg) should be restrained in a safety seat in the rear of
the car. The safety seat should be secured by a lap belt and a diagonal
belt. Children aged 6 - 11 years (22 - 36 kg) can use booster cushions
with safety belts, although child seats with a back rest are preferred.
Children should ride with a seatbelt positioned as for an adult only
when they can sit with their backs straight against the vehicle’s seat
with their knees bent over the edge of the seat, without slouching.
The shoulder and lap belt should fit comfortably across the shoulder,
lower abdomen and pelvic area. A child in a safety seat placed on the
front passenger seat of a vehicle equipped with front or side airbags
has an increased risk of injury and death in the event of a crash
through impact with the airbags.6
Correctly installed and used, child safety seats can reduce the risk of
death in the case of an accident by 71% in infants and 54% for children
aged 1 - 4 years (‘Seat-belts and child restraints: increasing use and
optimising performance’, European Transport Safety Council, 1996,
quoted in World Report on Road Traffic Injury Prevention,1 and
Will and Geller9). Unrestrained children seated in the rear are 35%
less likely to sustain fatal injuries than those seated in the front, and
44% less likely to sustain fatal injuries if they also use seatbelts.8,10 The
need for hospitalisation after an MVA among restrained children
aged 4 years and younger is reduced by 69%.11 Use of seatbelts by
children seated on the rear seat will reduce injuries not only to the
child but also to the driver and front passenger. Children seated on
the back of a ‘bakkie’ (a light motor vehicle with a rear load area)
cannot be appropriately restrained, and the practice of transporting
children in this manner should not be condoned.
Many countries have legislated the mandatory use of child restraints.
Yet, in an international study assessing seatbelt use in different
countries, only 42% of respondents felt that the current level of seatbelt
enforcement was ‘very good’.12 A study from the USA showed that 51%
of 3 - 8-year-olds are inappropriately restrained in adult safety belts.9
Despite the safety benefit of rear seating, 33% of children travelled in
the front seat of motor vehicles; this increased to 56% when there were
no adult or teenage passengers to sit in the front seat.13
A study done by the Medical Research Council of South Africa
(MRC) reports that only 14.3% of learners always wear a seatbelt,
and there is no significant variation by gender, ‘race’, age or grade.5 In
an invisible survey (the researcher remained unobserved and vehicles
were not stopped) done by Arrive Alive in most provinces of South
Africa, the percentage of drivers not wearing seatbelts ranged from
39.8% to 65.8%. Rates in urban areas were found to be even lower,
possibly because urban road users believe that accidents at lower
speeds are less perilous and seatbelts are therefore unnecessary.14
Given the high rates of mortality and injury of children involved in
MVAs, we investigated the seating position and use of child restraints
in Bloemfontein, as well as possible associated factors.
A descriptive study method with a cross-sectional analytic
component was chosen, and the study was carried out during a
4-week period in 2007. Bloemfontein was divided into more and less
affluent areas. Using a random table, five ‘more affluent’ and three
‘less affluent’ sites were chosen. Selected observation sites had to
have at least one pre-primary or primary school in the area. Stopping
points both near and away from the schools were selected for all sites.
Designated parking areas or stopping points on the school grounds
were not used, as children might already have been released from
their restraints. Four researchers (SFA, SB, PRD, JK) stood at each
stopping point. They had enough time and a sufficiently clear view
to record the assessments. The researchers worked in two pairs,
one person observing the motor vehicles, the other recording the
information. Only vehicles with children were included in the study.
A child was defined as a person estimated by the observers to be 12
years or younger. Older vehicles with no rear seatbelts were included
in the study, as the authors felt that car owners should have seatbelts
SAJCH JULY 2011 VOL. 5 NO. 2
fitted for optimal safety of passengers.15 Vehicles were categorised as
small (driver plus 3 passenger seats), medium (driver plus 4 passenger
seats) or large (driver plus 5 or more passenger seats). A vehicle was
judged to be overloaded if it was transporting more people than it was
designed for. Minibuses, buses and trucks, as well as motor vehicles
with tinted or covered windows, were excluded from the study.
The following observations were recorded by the researchers for
each child in a motor vehicle: seating position of the child, whether
child restraint was used and type of restraint, whether restraint was
assessed to be appropriate according to the child’s estimated age,
driver’s restraint, size of the vehicle, vehicle overloading, and whether
the observation point was in an affluent or less affluent area.
It was estimated that the appropriate use of child restraints would
be less than 10%. A sample size of 500 children would result in a
confidence interval of 7 - 13%. Therefore 16 sites were chosen, to
assess about 32 children per site.
A pilot study to test and refine the methodology was performed at
two stopping points, observing 60 children. Approval for the study
was obtained from the Ethics Committee of the Faculty of Health
Sciences of the University of the Free State as well as from the Chief
of Traffic of the Mangaung Municipality.
A total of 512 children in 374 vehicles were assessed. Most vehicles
carried only one (70.3% of vehicles) or two child passengers (25.1%
of vehicles).
Sixty per cent of the children were seated in the rear of the vehicle,
39.6% were seated in the front, and 0.4% were seated in the back of
an open bakkie. Of the 14.1% of children seated on other people’s
laps, 73.6% were on the front seat and 26.4% on the back seat.
Child restraint use in Bloemfontein was found to be 8.8% (95%
confidence interval (CI) 6.6 - 11.6%) and appropriate restraint use
to be 2.9% (95% CI 1.8 - 4.8%). None of the children sitting on laps
were restrained. Of children seated in the front, 10.3% were restrained
(only 2% appropriately), while in the rear only 7.8% were restrained
(only 3.6% appropriately). There was an association between the
affluence level of an area and child restraint use, with children in less
affluent areas being less likely to be restrained than their counterparts
in more affluent areas (1.0% v. 13.4% , p<0.0001) (Table I). A similar
association was seen between area affluence and appropriate use of
child restraints (p=0.0023). Driver restraint use was 17.4% (95% CI
13.9 - 21.5%). Twenty-four per cent of drivers in affluent areas were
restrained, versus only 5.8% of drivers in less affluent areas.
Table I. Child restraint use according to area Affluent
(N (%))
Less affluent
(N (%))
(N (%))
Not restrained
Restrained, but
not appropriately
There was a strong association between driver restraint and child
restraint (p<0.0001). (Table II). If a driver was restrained, the chance
that all the children in the vehicle would be restrained was 10 times
higher than when the driver was not restrained (95% CI 4.9 - 20.2).
Table II. Association between driver restraint use and child restraint use
No children restrained
(N (%))
All children restrained
(N (%))
Some children restrained
(N (%))
(N (%))
Driver not restrained
Driver restrained
The percentage of overloaded vehicles was 13.4% (95% CI 10.3 17.2%). There was an association between area affluence and vehicle
overloading (p<0.05); in affluent areas 9.3% vehicles were overloaded,
while in non-affluent areas 20.4% were overloaded. In all of the 50
overloaded vehicles no child was restrained, while in non-overloaded
vehicles 13% of children were restrained (p=0.0227).
The limitations of the study are accuracy in estimation of the age and
weight of the children (to assess appropriateness of child restraint)
and affluence of the area. A similar study in Nigeria in 2005, which
included 456 vehicles, showed that despite 95% of vehicles having
seatbelts installed for drivers, only 48% of drivers were restrained and
4.1% of all children were restrained. Children were more likely to be
restrained in vehicles where the driver was restrained (11.8% v. 3.5%).
Twenty-eight per cent of children occupied the front seat, but only
10.8% of these were restrained. Most of these children were under
the age of 4 years. Only 1.6% of children seated in the rear were
An American study has also shown that children are 3 - 4 times
less likely to be restrained if the driver is also unrestrained.16 Drivers
need to be buckled up and be held responsible for their passengers’
safety. Driver restraint is consistently associated with higher use of
restraints in children.8
In our study there was an association between child restraint use (and
appropriateness thereof ) and driver restraint use, vehicle overloading
and ‘affluence’ of the area where these were observed. There is
therefore a need to consider subsidising installation of safety belts in
vehicles that do not have seatbelts. Child seats and booster cushions
also need to be available at affordable prices. In the long term, the
costs will probably be recovered from savings due to fewer injuries
to child passengers.
Most developed countries have legislation to protect children
travelling in motor vehicles. In South Africa, the wearing of seatbelts
for passengers and drivers is compulsory in terms of regulation
213(4) of the National Road Traffic Regulation, under the National
Road Traffic Act, 1996 (Act No. 93 of 1996). Regulation 213(5) also
prohibits a person from occupying a seat that is not fitted with a
seatbelt while a seat with a belt is unoccupied. Since 1995, all new
cars in South Africa must have lap and shoulder belts on the front
seats and at least lap belts on the rear seats.17 For children aged
between 3 and 14 years, the law states that ‘The driver of a motor
vehicle operated on a public road shall ensure that a child seated on
a seat of the motor vehicle uses an appropriate child restraint where
it is available in the motor vehicle or, if no child restraint is available,
wears the seatbelt of an unoccupied seat which is fitted with a seatbelt,
if available.’18 However, there is no legal requirement for a child aged
less than 3 years to wear a seatbelt unless there is a child seat or
restraint, in which case the child must be seated and restrained in
it. The general apathy of South Africans towards the use of child
restraints begins with inadequate seatbelt laws for children. Despite
high injury figures, there is ‘an ambiguity about enforcement of safety
measures’, as well as an indifference of drivers to ensure the safety of
their passengers.2 The driver is liable for a fine should a passenger
or child not be wearing a seatbelt.19 Enforcement of seatbelt use in
South Africa was given a score of 2/10 by the WHO.4 Despite the
availability of information, there is no culture of appropriate child
seating and restraint use.
The process of reducing road traffic injuries and deaths by enforcing
appropriate behaviour is not difficult.20 In Finland the wearing of
seatbelts increased drastically after law enforcement. Information and
education campaigns were used only to emphasise the importance of
the laws.21 In a study from Cape Town on the reporting of paediatric
trauma and safety, there was a plea for greater coverage by the media
on the prevention of unintentional injuries. The media can assist with
education and advocacy for child passenger and driver restraint in
motor vehicles.22
The severity of child passenger injuries can be attenuated and deaths
can be prevented by using childhood restraints correctly.6 The ‘four
Es’ of injury prevention need to be applied23 (Table III).
We do not think that the problem is confined to Bloemfontein only;
a similar pattern is probably present in the rest of South Africa. The
World Health Organization recommends that member countries set
and enforce seatbelt and child restraint laws for all vehicle occupants.
A detailed manual has been published by the FIA (Fédération
Internationale de l’Automobile: Foundation for the Automobile and
Society). It is endorsed by four partner organizations (the World
Health Organization, World Bank, FIA and Global Road Safety
Table III. Prevention of injuries to child passengers in cars1,5,20-25
• A
wareness of legislation that drivers and passengers must wear restraints and
children to be seated on rear seats
• T
each older children
• Use of media, pamphlets, road safety programmes in schools
Environment modification
• Infant seats available for sale or hire at lower cost
• A
vailability and affordability of correct and age-appropriate child restraints
• All cars to be fitted with seatbelts, front and rear
• E
nforcement of legislation
• A
dding legislation for child restraints for children <4 years
• H
igh visibility of law enforcement
SAJCH JULY 2011 VOL. 5 NO. 2
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l of Child
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vehicle travel: From effective risk communication to
behavior change. J Safety Res 2004;35:263-274.
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factors affecting the risk of death for rear-seated
passengers in road crashes. Accid Anal Prev
11. Sangowawa A, Ekanem S, Alagh B, et al. Child
seating position and restraint use in the Ibadan
Metropolis, South Western Nigeria. African Safety
Promotion 2006;4(3):37-49.
12. Weiss H, Sirin H, Levine JA, Sauber E.
International survey of seat belt use exemptions. Inj
Prev 2006;12:258-261.
13. Greenberg-Seth J, Hemenway D, Gallagher SS,
Lissy KS, Ross JB. Factors associated with rear
seating of children in motor vehicles: A study in two
low-income, predominantly Hispanic communities.
Accid Anal Prev 2004;36:621-626.
14. Arrive Alive.
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disparities to address a global-health problem. Lancet 2006;367:1533-1540.
16. Glassbrenner D, Carra JS, Nichols J. Recent estimates of safety belt use. J Safety
Res 2004;35:237-244.
17. Harris GT, Olukoga IA. A cost benefit analysis of an enhanced seat belt
enforcement program in South Africa. Inj Prev 2005;11:102-105.
18. Republic of South Africa. National Road Traffic Act, 1996 (Act 93 of 1996).
Regulation No. 213.
roadregs06.html (accessed 13 December 2010).
19. Arrive
asp?mc=vehicle&nc=seatprotect (accessed 5 December 2007).
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interventions. S Afr Med J 2008;98(9):692-695.
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Prevention. Geneva: World Health Organization, 2004.
22. Hon JML, Van As AB. Paediatric trauma and safety in the media: An audit
of its coverage in a South African broadsheet. South African Journal of Child
Health 2009;3(2):40-43.
23. Van As S, Naidoo S. Paediatric Trauma and Child Abuse. Cape Town: Oxford
University Press Southern Africa, 2006:12-14.
24. D u W, Finch CF, Hayen A, Bilston L, Brown J, Hatfield J. Relative benefits of
population-level interventions targeting restraint-use in child car passengers.
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25. Hendrie D, Miller TR, Orlando M, et al. Child and family safety device
affordability by country income level: an 18 country comparison. Inj Prev
26. NSW Roads and Traffic Authority.
campaigns/outdoorbillboardandslogan (accessed 28 January 2009).
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l of Chstudy
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An American
has also shown that
a lt h
Partnership) and explains the planning and
management of a seatbelt programme and
how to develop, implement and evaluate such
a programme. It is aimed specifically at policy
makers and road safety practitioners and uses
experience from countries that have succeeded
in implementing high levels of restraint use.
The manual is adaptable to the specific needs
of a country.6 South Africa should urgently
tackle this problem to prevent unnecessary
injuries, permanent disabilities and deaths as
well as decrease financial losses. If the use of
restraints is enforced, there would be a direct
financial gain from less medical costs for the
acute care and rehabilitation of victims.15,17
children are 3 - 4
times less likely to
be restrained if
SA Jou
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3. Norman R, Matzopoulos R, Groenewald P, Bradshaw D. The high burden of
injuries in South Africa. Bull World Health Organ 2007;85(9):695-702.
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action. 2009.
eng.pdf (accessed 16 November 2010).
5. Donson H, ed. A profile of fatal injuries in South Africa 2007. MRC/Unisa
Crime, Violence and Injury Lead Programme.
nimss07.PDF (accessed 16 November 2010).
6. FIA Foundation for the Automobile and Society, World Health Organization,
Global Road Safety Partnership, World Bank. Seat-belts and Child Restraints:
A Road Safety Manual for Decision-makers and Practitioners. London: FIA
Foundation for the Automobile and Society, 2009:5.
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Think before you drive.
news/unrestrained_baby_on_board.html (accessed 11 December 2010).
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effective in school age children as in adults? A prospective crash study. BMJ
a lt h
Conflict of interest: None.
the driver
Safety as a human rights issue needs to receive
l of Cishilalso
priority attention.2 Drivers, traffic authorities
and politicians need to be convinced of
the importance of wearing seatbelts.1 Law
enforcement of correct child restraint use will
prevent much unnecessary suffering, and large
financial savings will ensue. The New South Wales Centre for Road
Safety (Australia) puts the message bluntly on an outside billboard
and bumper sticker: ‘No Belt. No Brains.’26
SAJCH JULY 2011 VOL. 5 NO. 2
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