CONSULTATION DRAFT
9.4 Travel
Discussing the risks associated with travel during pregnancy enables women to make informed
decisions and take measures to improve their safety.
9.4.1
Background
Studies have identified limited knowledge among women of factors associated with travel during
pregnancy, including the correct use of seat belts and risks associated with overseas travel.
Risks associated with travel in pregnancy
•
Car travel: Severe and non-severe injuries from motor vehicle accidents are associated with
adverse maternal and fetal outcomes (Schiff & Holt 2005; El Kady et al 2006; Hitosugi et al 2006; Wahabi et
al 2007; Aboutanos et al 2008; Klinich et al 2008; Kvarnstrand et al 2008; Schiff et al 2008; Weiss et al 2008; Cheng
et al 2012), with a higher risk of adverse outcomes if the birth takes place during an admission for a
motor vehicle accident (Vivian-Taylor et al 2012). Adverse maternal and fetal outcomes are more
likely following a motor vehicle accident if a seat belt is not worn (Hyde 2003; Klinich et al 2008;
Motozawa et al 2010). Airbag deployment does not appear to adversely affect maternal or fetal
outcomes (Metz & Abbott 2006; Schiff et al 2010).
•
Long-distance air travel: Commercial flights are normally safe for pregnant women (Freeman et al
2004; RCOG 2008; ACOG 2009) and frequent air travel during pregnancy (eg by flight crew members)
does not appear to increase the risk of adverse outcomes (Irgens et al 2003; dos Santos Silva et al 2009).
However, air travel at 34–37 weeks gestation has been associated with an increased risk of preterm
birth (Chibber et al 2006; Magann et al 2010). Venous thrombosis, which is associated with longdistance air travel in the general population (Belcaro et al 2001), is more likely in pregnancy.
•
Overseas travel: Exposure to infection is increased with travel to certain regions. Pregnant women
are more likely than non-pregnant women to become infected with malaria (Coll et al 2008).
Malaria during pregnancy is associated with spontaneous abortion, preterm birth, low birth weight,
stillbirth, congenital infection and maternal death (Lagerberg 2008).
9.4.2
Discussing travel during pregnancy
While the available evidence on travel in pregnancy is from low level studies and is heterogeneous, this
evidence largely supports the NICE recommendations.
Car travel
High-level evidence from general populations supports the use of seat belts (Glassbrenner & Starnes 2009).
However, studies examining pregnant women’s knowledge and compliance of seat belt use and
health professionals’ counselling on the use of seat belts in pregnancy have found a lack of
knowledge, compliance and advice given (McGwin et al 2004a; McGwin et al 2004b; Beck et al 2005; Jamjute
et al 2005; Taylor et al 2005; Sirin et al 2007). Information provided to pregnant women can promote correct
use of seat belts (McGwin et al 2004b).
The Confidential Enquiry into Maternal Deaths in the United Kingdom provides the following advice on
the correct use of seatbelts in pregnancy (Lewis & Drife 2001):
•
straps should be placed above and below the ‘bump’, not over it;
•
use three-point seatbelts with the lap strap placed as low as possible beneath the ‘bump’, lying
across the thighs with the diagonal shoulder strap above the bump lying between the breasts; and
•
adjust the fit to be as snug as comfortably possible.
Recommendation 30
Grade B
Inform pregnant women about the correct use of seat belts — that is, three-point seat belts ‘above
and below the bump, not over it’.
CONSULTATION DRAFT
Overseas travel
Overseas travel is increasingly common in pregnancy (McGovern et al 2007), and women are not always
adequately prepared in terms of travel advice and insurance (Kingman & Economides 2003). Travelrelated morbidity can be avoided by postponing the trip until after the birth, but this may not be
feasible due to family desire or emergent situations. It is important to convey the risks associated with
travel during pregnancy and to inform women of useful preventive interventions (McGovern et al 2007).
Long-distance air travel
The policies of commercial airlines regarding travel by pregnant women vary, with most limiting air
travel beyond 36 weeks gestation due to associated risks (Breathnach et al 2004).
A survey of women’s knowledge of air travel risks in pregnancy reported that only one-third of
respondents sought travel advice and one-quarter were unaware of the risk of venous thrombosis
(Kingman & Economides 2003). Advice on venous thrombosis provided by health professionals also varies
(ranging from simple preventive measures to use of aspirin or heparin) (Voss et al 2004).
Preventive measures to minimise the risk of venous thrombosis include (ACOG 2009; Brenner 2009):
•
using support stockings and periodic movement of the lower extremities;
•
avoiding restrictive clothing;
•
undertaking occasional ambulation; and
•
maintaining adequate hydration (eg drinking plenty of water and avoiding caffeine or alcohol).
Recommendation 31
Grade C
Inform pregnant women that long-distance air travel is associated with an increased risk of venous
thrombosis, although it is unclear whether or not there is additional risk during pregnancy.
Vaccinations
Some vaccinations for travel overseas are contraindicated in pregnancy. The NICE Guidelines (NICE
2008) advise:
•
in general, killed or inactivated vaccines, toxoids and polysaccharides can be given during
pregnancy, as can oral polio vaccine;
•
live vaccines are generally contraindicated because of largely theoretical risks to the baby; and
•
measles, mumps, rubella, BCG and yellow fever vaccines should be avoided in pregnancy.
The risks and benefits of specific vaccines should be examined for each woman and the advice of a
travel medicine doctor sought. Recommendations on vaccinations during pregnancy are included in
the Australian Immunisation Handbook and the World Health Organization provides interactive maps
on areas where the risk of specific infections is medium to high (see Section 9.4.4).
Travel insurance
Women should be advised to compare various policies and read the exclusion clauses carefully.
Practice point r
Pregnant women should be advised to discuss considerations such as air travel, vaccinations and travel
insurance with their midwife or doctor if they are planning to travel overseas.
Travel to malaria-endemic areas
Due to the risks associated with maternal malaria and potential adverse effects associated with
preventive medications, the safest option is for women to avoid travel to malaria-endemic areas during
pregnancy. When travel cannot be deferred, women should be advised about preventive measures
and any risks associated with them.
Taking precautions against mosquito bites is an important preventive measure. Insecticide-treated bed
nets have been shown to reduce malarial levels in the general population (Jacquerioz & Croft 2009) and
adverse outcomes among pregnant women (Gamble et al 2006). Other barrier measures include:
•
wearing clothes that have been pretreated with insecticide;
CONSULTATION DRAFT
•
wearing long-sleeved treated clothing when outdoors in the evening and at night; and
•
applying insect repellent regularly to exposed skin.
Barrier measures have the additional advantage of protecting against other mosquito-transmitted
infections, such as dengue fever, Japanese encephalitis and yellow fever.
Recommendation 32
Grade B
If pregnant women cannot defer travel to malaria-endemic areas, advise them to use insecticidetreated bed nets.
Medications to prevent malaria infection reduce antenatal parasite prevalence and placental malaria
among pregnant women, regardless of number of previous pregnancies (Garner & Gülmezoglu 2006).
Among women having their first or second baby, they also have positive effects on birth weight and
may reduce the risk of perinatal death (Garner & Gülmezoglu 2006).
The use of preventive medicine depends on the level of risk (eg travel destination, season, length of
stay). The Therapeutic Goods Administration (TGA) advises that the use of preventive medicines is
justified in high-risk situations (TGA 2013).
Practice point s
Beyond the first trimester, mefloquine is approved for use to prevent malaria. Neither malarone or
doxycycline are recommended for prophylaxis any time during pregnancy. Chloroquine (or
hydroxychloroquine) plus proguanil is safe but less effective so seldom used. For areas where only vivax
is endemic, chloroquine or hydroxychloroquine alone is appropriate.
Current information on specific medicines in pregnancy is available from the TGA and information on
areas where there is a risk of transmission of malaria is available from the WHO and the Centers for
Disease Control and Prevention (see Section 9.4.4).
The risks and benefits of specific anti-malarial medications should be examined for each woman and
the advice of an expert in travel medicine sought.
9.4.3
Practice summary: travel
When: Early in antenatal care and when women seek advice about travel during pregnancy.
Who: Midwife; GP; obstetrician; Aboriginal and Torres Strait Islander Health Practitioner; Aboriginal and
Torres Strait Islander Health Worker; multicultural health worker, infectious disease specialist, travel
medicine specialist.
Discuss the use of seat belts: Explain that using a seat belt will not harm the baby and will improve
outcomes should an accident occur. Describe how to fit the seat belt correctly.
Discuss air travel: If a woman is planning long-distance air travel during pregnancy, she should discuss
this with a health professional and make enquiries with individual airlines and travel insurers to
assess whether planned travel is possible. If travel is arranged, provide advice on minimising the
risk of venous thrombosis.
Discuss prevention of infection while travelling: Explain that vaccinations required for travel to some
destinations may be contraindicated during pregnancy. Provide advice on malaria prevention
to women who are unable to defer travel to malaria-endemic areas.
Take a holistic approach: Assist women who are planning to travel to access relevant services
(eg health professionals with expertise in travel medicine). Advise that they take their antenatal
record with them when travelling.
9.4.4
Resources
Carroll D (2004) Pre-travel preparation of the pregnant traveller. Brit Travel Health Assoc J 5: 20–23.
CDC Traveler’s Health http://wwwnc.cdc.gov/travel/
CONSULTATION DRAFT
DFAT (2013) Smart Traveller. Department of Foreign Affairs and Trade. Accessed 3 May 2013.
http://smartraveller.gov.au/
DoHA (2013) Australian Immunisation Handbook. 10th edition. Canberra: Department of Health and Ageing.
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/EE1905BC65D40BCFCA257B
26007FC8CA/$File/handbook10.pdf
Hezelgrave NL, Whitty CJM, Shennan AH et al (2011) Advising on travel during pregnancy. BMJ 342(1): d2506–06.
TGA (2013) Prescribing Medicines in Pregnancy Database. Therapeutic Goods Administration. Accessed 3 May 2013.
http://www.tga.gov.au/hp/medicines-pregnancy.htm
WHO (2010) Malaria, countries or areas at risk of transmission. World Health Organization. Accessed 23 February 2013.
http://gamapserver.who.int/mapLibrary/Files/Maps/Global_Malaria_ITHRiskMap.JPG
WHO interactive disease maps — http://apps.who.int/ithmap/
9.4.5
References
Aboutanos MB, Aboutanos SZ, Dompkowski D et al (2008) Significance of motor vehicle crashes and pelvic injury on
fetal mortality: a five-year institutional review. J Trauma 65(3): 616–20.
ACOG (2009) Air travel during pregnancy. ACOG Committee Opinion No. 443. Obstet Gynecol 114(4): 954–55.
Beck LF, Gilbert BC, Shults RA (2005) Prevalence of seat belt use among reproductive-aged women and prenatal
counseling to wear seat belts. Am J Obstet Gynecol 192(2): 580–85.
Belcaro G, Geroulakos G, Nicolaides AN et al (2001) Venous thromboembolism from air travel: the LONFLIT study.
Angiology 52(6): 369–74.
Breathnach F, Geoghegan T, Daly S et al (2004) Air travel in pregnancy: the 'air-born' study. Ir Med J 97(6): 167–68.
Brenner B (2009) Prophylaxis of travel-related thrombosis in women. Thromb Res 123 Suppl 3: S26–29.
Cheng HT, Wang YC, Lo HC et al (2012) Trauma during pregnancy: a population-based analysis of maternal
outcome. World J Surg 36(12): 2767–75.
Chibber R, Al-Sibai MH, Qahtani N (2006) Adverse outcome of pregnancy following air travel: a myth or a concern?
Aust N Z J Obstet Gynaecol 46(1): 24–28.
Coll O, Menendez C, Botet F et al (2008) Treatment and prevention of malaria in pregnancy and newborn. J Perinat
Med 36(1): 15–29.
dos Santos Silva I, Pizzi C, Evans A et al (2009) Reproductive history and adverse pregnancy outcomes in commercial
flight crew and air traffic control officers in the United Kingdom. J Occup Environ Med 51(11): 1298–305.
El Kady D, Gilbert WM, Xing G et al (2006) Association of maternal fractures with adverse perinatal outcomes. Am J
Obstet Gynecol 195(3): 711–16.
Freeman M, Ghidini A, Spong CY et al (2004) Does air travel affect pregnancy outcome? Arch Gynecol Obstet
269(4): 274–77.
Gamble C, Ekwaru JP, ter Kuile FO (2006) Insecticide-treated nets for preventing malaria in pregnancy. Cochrane
Database Syst Rev(2): CD003755.
Garner P & Gülmezoglu AM (2006) Drugs for preventing malaria in pregnant women. Cochrane Database Syst
Rev(4): CD000169.
Glassbrenner D & Starnes M (2009) Lives Saved Calculations for Seat Belts and Frontal Air Bags. Washington: US
Department of Transportation National Highway Traffic Safety Administration.
Hitosugi M, Motozawa Y, Kido M et al (2006) Traffic injuries of the pregnant women and fetal or neonatal outcomes.
Forensic Sci Int 159(1): 51–54.
Hyde L (2003) Effect of motor vehicle crashes on adverse fetal outcomes. Obstet Gynecol 102(2): 279–86.
Irgens Å, Irgens LM, Reitan JB et al (2003) Pregnancy outcome among offspring of airline pilots and cabin
attendants. Scand J Work Environment Health 29(2): 94–99.
Jacquerioz FA & Croft AM (2009) Drugs for preventing malaria in travellers. Cochrane Database Syst Rev(4):
CD006491.
Jamjute P, Eedarapalli P, Jain S (2005) Awareness of correct use of a seatbelt among pregnant women and health
professionals: a multicentric survey. J Obstet Gynaecol 25(6): 550–53.
Kingman CE & Economides DL (2003) Travel in pregnancy: pregnant women's experiences and knowledge of health
issues. J Travel Med 10(6): 330–33.
Klinich KD, Flannagan CA, Rupp JD et al (2008) Fetal outcome in motor-vehicle crashes: effects of crash
characteristics and maternal restraint. Am J Obstet Gynecol 198(4): 450 e1–9.
Kvarnstrand L, Milsom I, Lekander T et al (2008) Maternal fatalities, fetal and neonatal deaths related to motor
vehicle crashes during pregnancy: a national population-based study. Acta Obstet Gynecol Scand 87(9):
946–52.
Lagerberg RE (2008) Malaria in pregnancy: a literature review. J Midwifery Womens Health 53(3): 209–15.
Lewis G & Drife J, Eds. (2001) Why Mothers Die 1997–1999: The Fifth Report of the Confidential Enquiries into Maternal
Deaths in the United Kingdom. London: Royal College of Obstetricians and Gynaecologists Press.
Magann EF, Chauhan SP, Dahlke JD et al (2010) Air travel and pregnancy outcomes: a review of pregnancy
regulations and outcomes for passengers, flight attendants, and aviators. Obstet Gynecol Surv 65(6): 396–
402.
CONSULTATION DRAFT
McGovern LM, Boyce TG, Fischer PR (2007) Congenital infections associated with international travel during
pregnancy. J Travel Med 14(2): 117–28.
McGwin G, Russell SR, Rux RL et al (2004a) Knowledge, beliefs, and practices concerning seat belt use during
pregnancy. J Trauma Injury Infect Crit Care 56(3): 670–75.
McGwin G, Jr., Willey P, Ware A et al (2004b) A focused educational intervention can promote the proper
application of seat belts during pregnancy. J Trauma 56(5): 1016–21.
Metz TD & Abbott JT (2006) Uterine trauma in pregnancy after motor vehicle crashes with airbag deployment: A 30case series. J Trauma 61(3): 658–61.
Motozawa Y, Hitosugi M, Abe T et al (2010) Effects of seat belts worn by pregnant drivers during low-impact collisions.
Am J Obstet Gynecol 203(1): 62 e1–8.
NICE (2008) Antenatal Care. Routine Care for the Healthy Pregnant Woman. National Collaborating Centre for
Women’s and Children’s Health. Commissioned by the National Institute for Health and Clinical Excellence.
London: Royal College of Obstetricians and Gynaecologists Press.
RCOG (2008) Air Travel and Pregnancy. Scientific Advisory Committee Opinion Paper 1. London: Royal College of
Obstetricians and Gynaecologists.
Schiff MA & Holt VL (2005) Pregnancy outcomes following hospitalization for motor vehicle crashes in Washington
State from 1989 to 2001. Am J Epidemiol 161(6): 503–10.
Schiff MA, Tencer AF, Mack CD (2008) Risk factors for pelvic fractures in lateral impact motor vehicle crashes. Accid
Anal Prev 40(1): 387–91.
Schiff MA, Mack CD, Kaufman RP et al (2010) The effect of air bags on pregnancy outcomes in Washington State:
2002-2005. Obstet Gynecol 115(1): 85–92.
Sirin H, Weiss HB, Sauber-Schatz EK et al (2007) Seat belt use, counseling and motor-vehicle injury during pregnancy:
results from a multi-state population-based survey. Matern Child Health J 11(5): 505–10.
Taylor AJ, McGwin G, Jr., Sharp CE et al (2005) Seatbelt use during pregnancy: a comparison of women in two
prenatal care settings. Matern Child Health J 9(2): 173–79.
TGA (2013) Prescribing Medicines in Pregnancy Database. Therapeutic Goods Administration. Accessed: 3 May
2013. http://www.tga.gov.au/hp/medicines-pregnancy.htm
Vivian-Taylor J, Roberts CL, Chen JS et al (2012) Motor vehicle accidents during pregnancy: a population-based
study. BJOG 119(4): 499–503.
Voss M, Cole R, Moriarty T et al (2004) Thromboembolic disease and air travel in pregnancy: a survey of advice given
by obstetricians. J Obstet Gynaecol 24(8): 859–62.
Wahabi HA, Saleh AT, Abdelrahman AA (2007) Motor vehicle accidents during pregnancy. A review of maternal
and fetal outcomes in Saudi Arabian population. Saudi Med J 28(9): 1456–57.
Weiss HB, Sauber-Schatz EK, Cook LJ (2008) The epidemiology of pregnancy-associated emergency department
injury visits and their impact on birth outcomes. Accid Anal Prev 40(3): 1088–95.