EBB 117 – The Evidence on Inducing for Due Dates – Evidence Based Birth®

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Hi, everyone. On today’s podcast, we’re going to talk about the evidence on inducing labor for going past your due date.

Welcome to the Evidence Based Birth podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.

Hi, everyone. On today’s podcast, we’re going to talk about the evidence on inducing versus waiting for labor when you’re going past your due date. I’m going to be joined by Anna Bertone, MPH, our Research Editor at Evidence Based Birth to talk about this topic.

Before we get started, I have a quick announcement, and that is next week we are hosting free webinars for the public all about the Evidence Based Birth Childbirth Class. On Monday, March 2, we’ll host a special webinar just for parents. We’ll give you a peek behind the scenes at what it’s like to take our Evidence Based Birth Childbirth Class. Then on Tuesday, March 3, we’ll have a special webinar just for birth professionals to give you a tour of the Evidence Based Birth Childbirth Class so that you can decide if it’s something you’d like to recommend to your clients or not. You can register for these free webinars at evidencebasedbirth.com/childbirthclasswebinar. That’s all one word /childbirthclasswebinar.

All right, now back to the topic at hand, inducing labor for going past your due dates. Now before we begin, I do want to give a brief trigger warning. In our discussion about the research evidence on this topic, we will be talking about stillbirth and newborn death. So there has been a ton of new research on the evidence on induction versus waiting for labor when you go past your due date. So much research, in fact, that we have decided to separate our Signature Article on due dates into two separate articles.

So we still have the original article, The Evidence on Due Dates, which you can find at ebbirth.com/duedates. And although we updated that article a little bit, it’s remained very similar to previous additions. It talks about the length of a normal pregnancy, factors that can make you more or less likely to have a long pregnancy, et cetera. But then we separated out the research on induction into a new article that you can find at ebbirth.com/inducingduedates. This is a peer-reviewed article that covers all of the research on induction versus something called “expectant management” for going past your due date. And in today’s podcast, we’re going to update you on the latest info that we found for that article.

Just a heads up, we will not be covering the research evidence on inducing at 39 weeks. We already covered the ARRIVE study, a randomized trial that looked at induction versus expectant management for 39 weeks of pregnancy in episode 10 of the Evidence Based Birth podcasts. And just a tip, if you’re having trouble finding any of our earlier episodes of this podcast, iTunes has stopped showing the earliest podcasts, but they’re still out there and you can find them on Spotify and any other podcasting app. You can also find info about the ARRIVE study at ebbirth.com/arrive.

So we’re not going to talk about induction at 39 weeks. Instead, we’re going to be focusing on the evidence on induction versus waiting for labor once you reach 41 weeks. And to do so, we’re going to talk with our Research Editor, Anna. So welcome, Anna, to the Evidence Based Birth podcasts.

Anna Bertone:   Thank you! I’m glad to be on the podcast again.

So I want to start by explaining to our audience a little bit kind of about the background of why this topic is important. Inductions for non-medical reasons have been on the rise in the United States and all around the world for the past 30 years. And increasingly, more people who are pregnant are being induced for reaching their estimated due date. So we really want to cover the benefits and risks of elective induction for going past your estimated due date. And we’ll also talk about whether or not your goals and preferences for your birth matter, which of course they do, but that kind of plays a role as well.

So how often are people induced for going past their due date? Well, we don’t know for sure because this hasn’t been measured recently. But according to the 2013 Listening to Mothers III survey, which was now published about seven years ago, more than 4 out of 10 mothers in the U.S. said that their care provider tried to induce labor. Inducing labor for going past your due date was one of the most common reasons for an induction. Out of everyone who had an induction in this study, 44% said they were induced because their baby was full term and it was close to the due date. Another 18% said that they were induced because the healthcare provider was concerned that the mother was overdue.

The Centers for Disease Control in the U.S. also reported in 2018 that about 27% of people had their labor induced, but we think that number is probably low and that the percentage of people who have labor induced is under-reported in the Vital Statistics Program in the United States. So Anna, can you talk a little bit about why there’s so much controversy over this concept of electively inducing labor once you go past your due date?

Anna Bertone:   So why is there so much controversy about elective induction? Elective inductions by definition are labor inductions that do not have a clear medical reason for taking place. They occur for social reasons, like the provider wanting the mother to give birth before the provider goes out of town or for other non-medical reasons like the pregnancy getting uncomfortable and for the mother’s convenience. But there’s also a gray zone about what constitutes an elective induction. Many providers only consider an induction to be “elective” when the mother is healthy, pregnant with a single baby, and less than 41 weeks pregnant. The gray zone is that sometimes when the pregnancy goes past 41 weeks, some providers consider that to be a medically indicated induction rather than an elective induction. But in general, inductions are considered medically indicated when there are accepted medical problems or complications with the pregnancy that make it less safe to continue the pregnancy.

For many years, and I remember when I first entered the birth world in 2012, a lot of people talked about the fact that if you have an induction it doubles your chance of cesarean. And then all of a sudden there were people saying that wasn’t true. So can you talk a little bit about that controversy?

Anna Bertone:   So for many years, the common belief was that elective induction doubles the cesarean rate, especially in first-time mothers. But researchers nowadays consider those earlier studies to be flawed. In the earlier studies, what they would do is they would compare people assigned to elective induction to people who went into spontaneous labor. Nowadays, they don’t compare those two groups anymore. They compare people assigned to elective induction to the people assigned to what’s called expectant management, or in other words waiting for labor. And in that group, the person could either go into spontaneous labor or they could require an induction for medical reasons (so that would be a medically indicated induction), or they could choose elective induction further along in the pregnancy.

So that’s a subtle difference but an important one because in the earlier studies they compared elective induction to spontaneous labor. But you don’t have the choice to go into spontaneous labor today. Your choice is to be induced today or to wait for labor to start. And sometimes during that waiting period you might develop complications that require an induction, or you might change your mind and decide to have an elective induction, or you might go into spontaneous labor.

Anna Bertone:   Right. So nowadays, we compare a group assigned to elective induction to a group assigned to expectant management. One example of this was the ARRIVE trial.

The ARRIVE trial was a study comparing elective induction at 39 weeks versus expectant management. We’re not going to go into that trial in detail because we already covered it in detail in episode 10 of the Evidence Based Birth podcasts. But they actually found a lower risk of cesarean in the elective induction group. Researchers think that had to do with the fact that of the people in the expectant management group, more of them developed problems with blood pressure that required medical inductions and increased risk for complications. So again, that just kind of goes to show you that it does make a difference when you compare elective induction to expectant management.

Although, one thing you have to keep in mind with the ARRIVE study is that they had a very low cesarean rate in both groups compared to some settings. The cesarean rate was 19% in the elective induction group versus 22% in the expectant management group. So those research results cannot probably be generalized to settings with extremely high cesarean rates or high cesarean rates with inductions. We have some, for example, some professional members at Evidence Based Birth who talked to us about where they’re practicing and how high the cesarean rates are with the elective inductions there. So I think you have to be careful how you generalize or apply that data from the ARRIVE study, and we talk more about that in episode 10 of the podcast.

Which leads me to another point, and that is some cautions about the evidence. When I say generalize, that means taking research from a research study, and seeing if you can apply that to where people are giving birth in your community. So it’s important to understand that there are some major drawbacks to some of the research that we’re going to be talking about. Many of the studies are carried out in countries or time periods where there are low cesarean rates. So when that happens, when a study is carried out in a setting where culturally there’s low C-section rates, that might not apply to a hospital with high cesarean rates. If your hospital has high rates of “failed inductions” and strict time limits on the length of labor, then the evidence in these studies may not apply to you because induction might be more risky in your community hospital.

Also, another disclaimer about the evidence, in these trials, people are randomly assigned to induction or expectant management. And it’s important to remember that the people assigned to expectant management do not always go into labor spontaneously. There’s a mix of people in that group. Some of them do have a spontaneous labor. Others have an elective induction later on, and others have a medical induction for complications.

Also, you have to look at what they’re doing for fetal testing in the studies. In some studies there’s lots of fetal testing going on in the expectant management group. However, we’re going to talk about one of the studies where they were not doing any standard fetal monitoring during expected management. So those results might not apply to your community if your community does the fetal monitoring, and the study did not have fetal monitoring.

Finally, another disclaimer about the research evidence is that the induction protocols vary from study to study, and even within studies themselves. So knowing what the protocol was for induction in that study can be very helpful to decide if this is going to apply to your unique situation in your local community or not.

So with all of those disclaimers being said, there’s been quite a lot of new research in the past year about induction at 41 weeks. So Anna, can you talk about one of the most recent studies? Let’s talk about the INDEX trial from the Netherlands. There were two trials that came out in 2019, two large randomized control trials. Let’s talk about the INDEX one first.

Anna Bertone:   Sure. So the INDEX trial was from the Netherlands. INDEX stands for induction at 41 weeks, expectant management until 42 weeks. This was a large multicenter trial. It was conducted at 123 midwifery practices and 45 hospitals. Most of these pregnancies were managed by midwives.

…So this was the midwifery-led model of care-

Anna Bertone:   Exactly.

… which is very different than in the United States which is typically an obstetrician-led care model.

Anna Bertone:   The researchers randomly assigned a total of 1,801 pregnant people to either induction at 41 weeks and zero to one days or to wait for labor until 42 weeks and zero days, which is called expectant management. The reason they were able to conduct this study in the Netherlands and got ethical approval for it is because it was standard practice for them to not induce labor before 42 weeks with an uncomplicated pregnancy.

…Whereas in the U.S. it’s rare to see someone go to 42 weeks, in the Netherlands, they typically won’t induce you unless there’s medical reasons until you get to 42 weeks – 

Anna Bertone:   Exactly. So the mothers were enrolled in the study between 2012 and 2016. Everyone had to be healthy, and pregnant with single, head-down babies. The gestational ages were estimated with ultrasound before 16 weeks of pregnancy. They excluded people with a prior cesarean, with high blood pressure disorders, with expected problems with the baby’s growth, abnormal fetal heart rate, or known fetal malformations (congenital anomalies). In both groups, cervical ripening and induction methods depended on local protocol. It’s like what Rebecca was talking about earlier. There wasn’t a standard protocol to apply to both groups in this study when it came to cervical ripening and induction. It was based on local protocol. And this is an important weakness of the study because the providers might’ve managed labor inductions differently based on whether someone was being electively induced or was assigned to the expectant management group. It also limits the study’s generalizability, which means our ability to apply the results of this study to the population at large because providers don’t have an induction protocol that they can replicate.

…So we can learn from what happened in this study, but it’s difficult for us to apply it to across the board because there’s no specific induction protocol that could be followed – 

Anna Bertone:   Yeah. What happened was in the elective induction group, 29% of the participants went into labor before their induction and 71% were induced. Then in the expectant management group, 74% of the participants went into labor spontaneously before their planned induction and 26% were induced.

…And before we talk about how long the pregnancies were, I think it’s important for people to understand that when you have a randomized controlled trial like this the researchers do something called intent to treat analysis. So it doesn’t matter what type of birth they had, whether it was a spontaneous labor or a medical induction, the data were analyzed depending on which group you were originally assigned to. So if you were assigned to an elective induction but you happen to just quick go into labor on your own before the induction, you were still grouped with everyone in the elective induction group and vice versa. So that’s just an important distinction for people to understand. – 

Anna Bertone:   Yes. What happened with these results is that the median pregnancy was only two days shorter in the elective induction group compared to the expectant management group. This is interesting because they still found a difference between these two groups, but-

…And this is important because a lot of people ask us like, “Well, I only want to wait one more day, or two more days, or three or four more days,” but they’re saying by decreasing the length of the pregnancy by two days they found significant results. So what did they find in the INDEX trial? – 

Anna Bertone:   So for mothers, they found that there was no difference in the cesarean rates. This was taking place in a country with low cesarean rates. It was a midwifery model of care and the rates were very low in both groups (11%). 

They only had an 11% cesarean rate then?

Anna Bertone:   Yeah. They also had an outcome called a composite outcome, which is a combined outcome for mothers, and there was no difference in that measure either. They were looking for things like excessive bleeding after birth, manual removal of the placenta, severe tears, intensive care admission, and maternal death, and they didn’t find a difference in those things. There were no maternal deaths in either group. So as far as the bad outcomes for the mothers, there were about 11% to 14% in both groups, but not different.

…And what about for the babies then? – 

Anna Bertone:   And then for the babies, the babies in the elective induction group had a lower composite outcome rate. And in this composite outcome, what they were looking at was perinatal death, Apgar score less than seven at five minutes, low pH, meconium aspiration syndrome, nerve injury, brain bleeds, or admission to a NICU. And here they found a lower composite adverse outcome rate with the babies in the elective induction group (1.7% versus 3.1%). 

And why do they think that outcome was better with the elective induction group?

Anna Bertone:   They think that it was mostly due to the lower rate of Apgar scores less than seven at five minutes, and that probably contributed the most to having a lower adverse outcome rate with the babies in the elective induction group. The author’s note that there was no difference in rates of Apgar score less than four at five minutes, but they found that the combined outcome was still lower in the elective induction group if they used an Apgar score of less than four at five minutes and excluded fetal malformations. So basically, the babies in the elective induction group had better Apgar scores overall.

…And what about stillbirths? Because that’s like the main reason they’re doing these kinds of elective inductions, is to lower the risk of stillbirth. – 

Anna Bertone:   Yep. And they did not find a difference in stillbirth in this study. There was one stillbirth that occurred in the elective induction group. It was at 40 weeks and six days, before the mother was induced. Then, there were two stillbirths that occurred in the expectant management group while the mothers were waiting for labor.

Anna Bertone:   I looked for a few more details about those stillbirths because I was interested in that. Of the two stillbirths that occurred in the expectant management group, one was a small for gestational age baby at 41 weeks and three days to a first-time mother. The other one was to a mother with a prior birth, and that was at 41 weeks and four days. The mother’s placenta showed signs of infection (infection of the membranes). Then, the one stillbirth that occurred at in the elective induction group at 41 weeks was to an experienced mother (someone who had already had given birth before), and that was at 40 weeks and six days, and there was no explanation for that one. But with two versus one, they didn’t find a significant differences in stillbirths between those groups.

And what was the protocol for fetal monitoring in that study?

Anna Bertone:   There was no protocol for fetal monitoring. It depended on local guidelines, just like the induction and cervical ripening protocol. But the study authors say that fetal monitoring and assessment of amniotic fluid levels was typically done between 41 and 42 weeks. 

So how would you sum up the results of this INDEX study then?

Anna Bertone:   They found that elective induction at 41 weeks resulted in similar cesarean rates and less overall bad outcomes for babies compared to waiting for labor until 42 weeks. However, they say that the absolute risk of a bad outcome happening was low in both groups. It was 1.7% in the elective induction group versus 3.1% in the expectant management group (the group that waited until 42 weeks).

All right. Well, the next study we wanted to talk about was the SWEPIS trial from Sweden, also published in 2019, also coming out of Europe. It’s S-W-E-P-I-S, and it stands for the Swedish post-term induction study, or SWEPIS. It got a lot of media attention with headlines like … There was one that said, “Post-term pregnancy research canceled after six babies died.” And it is true that this study was ended early after deaths in the study. The researchers intended to enroll 10,000 mothers from multiple centers across Sweden, but they ended up stopping the study with about 1,380 people in each group after their data safety and monitoring board found a significant difference in perinatal death between the groups.

Data safety and monitoring boards are basically a board that keeps track of what’s going on in the study. They get interim reports. And if they see any concerning safety issues, they have the power to stop the studies. That’s a standard part of a lot of randomized controlled trials is to have one of these safety boards.

Similar to the INDEX trial in the Netherlands, in Sweden, labor is typically not induced before 42 weeks if you have an uncomplicated pregnancy. Also similar to the Netherlands, in Sweden, midwives manage most of the pregnancies and births. It’s a midwifery-led model of care.

The purpose of the SWEPIS study was to compare elective induction at 41 weeks and zero to two days versus expectant management and induction at 42 weeks and zero to one day if the mother hadn’t gone into labor by that point. The study was carried out in the years 2015 to 2018. The researchers enrolled healthy mothers with single babies in head-first position. They had accurate gestational ages. They excluded people with a prior cesarean, diabetes, and other complications such as high blood pressure, small for gestational age, or known fetal malformations.

There is a pretty low stillbirth rate in Sweden, so they thought they would need about 10,000 people to see a difference between groups, but they ended up not needing nearly that many people to find a difference in stillbirth rates. One of the big strengths of the SWEPIS trial is that in contrast to the INDEX trial, in the SWEPIS trial they defined an induction protocol and they used that same protocol with everyone in the elective induction group and everyone in the expected management group who had an induction. The protocol was basically if the mother’s cervix was already ripe, they simply broke her water and gave her oxytocin as needed by IV. If the mother’s cervix was not ripe or the baby’s head was not engaged, they used mechanical methods or Misoprostol, or prostaglandins, or oxytocin, but they did cervical ripening first.

In the elective induction group, most of the people were induced. 86% had their labor induced. 14% went into labor spontaneously before the induction. In the expectant management group, 67% of them went into labor spontaneously and 33% ended up with an induction. Similar to the INDEX trial, there was a really tiny difference in the length of pregnancy between groups. Pregnancy in the elective induction group was in general only three days shorter than pregnancy in the expectant management group, but yet they did go on to find significant differences.

So what the SWEPIS trial found was that for babies – this is why this study was stopped early – there were five stillbirths and one early newborn deaths in the expectant management group out of 1,379 participants for a death rate of 4.4 deaths per 1,000 women. There were zero deaths in the elective induction group out of 1,381 participants. All five stillbirths in the expectant management group happened between 41 weeks, two days and 41 weeks, six days. Three of the stillbirths had no known explanation. One was for a baby that was small for gestational age. The other was with a baby who had a heart defect. There was one newborn death that occurred four days after birth due to multiple organ failure in a baby that was large for gestational age.

The authors mentioned that when complications are present at the end of pregnancy, such as problems of the placenta, or the umbilical cord, or fetal growth, these problems may become increasingly important as each day of pregnancy progresses, which they believe is why they found a higher death rate with expectant management past 41 weeks.

Another key finding of the study was that all of these deaths occurred to first-time mothers, which suggests that 41-week induction may be especially beneficial for babies of first-time mothers. They found that it only took 230 inductions at 41 weeks to prevent one death for a baby, and this was a much lower number than previously thought. If you remember, though, as Anna was saying, the INDEX trial did not find a significant difference in death between the induction group and the expectant management group. We think the reason the SWEPIS study found a difference was because it was a larger study, it was better able to detect differences in rare outcomes like death. Also, with the SWEPIS study, there might not have been as good fetal monitoring. So it’s possible that the better fetal monitoring of participants between 41 weeks and 42 weeks in the INDEX trial might’ve been protective, leading to fewer perinatal deaths. We can’t be certain though because there were no fetal monitoring protocols in either trial.

Another thing to note is that participants in the SWEPIS expectant management group tended to give a birth a little later than the participants in the INDEX expectant management group. That might help explain the higher perinatal death rate in the expectant management group in SWEPIS. They did not find a difference in what they call the composite adverse perinatal outcome, which included death, low Apgar scores, low pH, brain bleeds, brain injury, seizures, and several other major complications, but there was that significant difference in perinatal death (either having a stillbirth or newborn death).

Also, the elective induction babies were less likely to have an admission to intensive care, 4% versus 5.9%. They had fewer cases of jaundice, 1.2% versus 2.3%, and fewer of them were big babies, 4.9% versus 8.3%.

For mothers, the outcomes were overall pretty good. There were no differences in cesarean rates similar to the other trial. The cesarean rate in this study in both groups was about 10% to 11%. More mothers in the elective induction group had an inflammation of the inner lining of the uterus called endometritis, 1.3% versus 0.4%. And on the other hand, more mothers in the expected management group developed high blood pressure, 3% versus 1.4%. They also interviewed the women in both groups and they found that the mothers in the expectant management group really struggled with negative thoughts. They described feeling in limbo while they waited to go into labor. So Anna, can you talk a little bit about the fetal monitoring in this study and how it may have differed from the other study?

Anna Bertone:   Sure. Fetal monitoring in this study was done per local guidelines. So there was no study protocol for fetal monitoring during the 41st week of pregnancy. However, the mothers recruited from one region of Sweden, called the Stockholm region, which made up about half the people in the study, had ultrasound measurements of their amniotic fluid volume and abdominal diameter at 41 weeks, whereas the people that came from the other areas of Sweden in the study did not receive these assessments regularly. None of the six deaths that occurred in this study occurred in the Stockholm region of Sweden where they received this type of fetal monitoring, which leaves us with the question of how important was this fetal monitoring. Could it have made the difference between the Stockholm region participants not experiencing fetal deaths whereas participants from other regions did?

Anna Bertone:   So that’s just an important thing to keep in mind with this study is that the fetal monitoring may have made a difference as far as the perinatal outcomes. It also means that the results of the SWEPIS study might not apply equally to mothers who receive fetal monitoring at the end of pregnancy, specifically during that 41st week of pregnancy which seems to be the really critical time period. Another thing, all of the perinatal deaths in this study occurred to first-time mothers, which tells us that the results might not apply equally to mothers who have already given birth before.

…So in the SWEPIS study, out of the mothers in the study who had already given birth before and were having a subsequent baby, none of them experienced this stillbirth or newborn death, correct?

Anna Bertone:   Correct. Yes.

Okay. So all of the perinatal deaths occurred to first-time mothers.

Anna Bertone:   And the first-time mothers, by the way, they only made up about half of the participants in the sample, so it was about a 50/50 split.

So all of the fetal and newborn deaths from this study came from first-time mothers who lived in the areas of Sweden that did not do any prescribed fetal monitoring during that 41st week of pregnancy.

Anna Bertone:   That’s my understanding. Correct.

Okay. So those are the two big randomized trials that came out in 2019. Before they were published, there was a 2018 Cochrane meta-analysis. Anna, I was wondering if you could talk a little bit about that. This study did not include the SWEPIS and the INDEX trials, but we still wanted to talk about it in our article. So can you explain to our listeners a little bit about this Cochrane review?

Anna Bertone:   Sure. There was a 2018 Cochrane review and meta-analysis by Middleton. Unlike these randomized control trials that we were just talking about, they didn’t focus specifically on the 41st week of pregnancy versus the 42nd week of pregnancy. It was much more broad than that. What they did was they looked at people who were electively induced at some point, and compared them to people who waited for labor to start on its own until some point. So there was a much more broad range of gestational ages there. But they included 30 randomized control trials with over 12,000 mothers, and they compared a policy of induction at or beyond term versus expectant management. All of the trials took place in Norway, China, Thailand, the U.S., Austria, Turkey, Canada, the UK, India, Tunisia, Finland, Spain, Sweden, and the Netherlands.

So it’s quite a global sample.

Anna Bertone:   Yes. But one study in this meta-analysis really dominated and accounted for about 75% of the data, and that was the Hannah post-term trial that I think Rebecca is going to be talking about soon. Because that one trial dominated this meta-analysis so much, most of the data was on giving birth at 41 weeks or later.

And they did not include the ARRIVE trial in this meta-analysis.

Anna Bertone:   Right. They didn’t include the ARRIVE, INDEX, or SWEPIS trials. So in its next update, it’s going to be updated with those three randomized control trials. But they did include 30 other randomized control trials. What they found was that a policy of induction at term or beyond term was linked to 67% fewer perinatal deaths compared to expectant management. So that was two deaths with induction at or beyond term versus 16 deaths in the people assigned to expected management.

Anna Bertone:   The Hannah post-term trial excluded deaths due to fetal malformations, but some of the smaller trials that were included in the Cochrane meta-analysis did not. So if we exclude the three deaths from severe fetal malformations, then the final count is one death in the induction group and 14 in the expectant management group. So it doesn’t change the results too much overall to exclude fetal malformations. Overall, they found that the number needed to treat was 426 people with induction at or beyond term to prevent one perinatal death. Specifically, there were fewer stillbirths with a policy of induction at or beyond term.

Which was a different number needed to treat than the SWEPIS trial, which found only took 230 inductions at 41 weeks to prevent one perinatal death.

Anna Bertone:   Yeah. I think part of the reason the SWEPIS trial was so groundbreaking and got so much media attention is because it did find a lower number needed to treat than had been found previously. So the absolute risk of perinatal death was 3.2 per 1,000 births with the policy of expected management versus 0.4 deaths per 1,000 births with the policy of induction at or beyond term. They found that a policy of induction was linked to slightly fewer cesareans compared to expectant management, 16.3% versus 18.4%.

Anna Bertone:   Fewer babies assigned to induction had Apgar scores less than seven at five minutes compared to those assigned to expectant management. They didn’t find any differences between the groups with the rate of forceps or vacuum assistance at birth, perinatal trauma, excessive bleeding after birth, total length of hospital stay for the mother, newborn intensive care admissions, or newborn trauma. The authors concluded that individualized counseling might help pregnant people choose between elective induction at or beyond term or continuing to wait for labor. They stress that providers should honor the values and preferences of the mothers.

We need more research to know who would or would not benefit from elective induction. And the optimal time for induction is still not clear from the research, which is what they said in 2018. I think Rebecca’s going to talk about the famous Hannah post-term study that accounted for 75% of the data in that meta-analysis.

Yeah, so we’re kind of working backwards through time. We started with the 2019 randomized trials, then the 2018 meta-analysis where they said the optimal time for induction is not clear, but they stated that before the two new randomized trials came out. Then even before then going back in time is the 1992 Hannah post-term study, which is one of the most important studies on inducing for going past your due date and it was the largest randomized trial ever done on this topic, larger even than INDEX or SWEPIS. And it controls most of the findings in that Cochrane meta-analysis that Anna just described.

So let’s look at what happened in this study because it plays so much of a role in the meta-analysis. It was carried out between the years 1985 and 1990 when a group of researchers enrolled 3,407 low-risk pregnant people from six different hospitals in Canada into the study. Women could be included if they were pregnant with a live single fetus, and they were excluded if they were already dilating, if they had a prior cesarean, pre-labor rupture membranes, or a medical reason for induction.

This study had a much different expectant management protocol than INDEX or SWEPIS because unlike those studies where the longest you would go was 42 weeks and zero to one or two days, in the Hannah post-term study, the people assigned expectant management were monitored for as long as 44 weeks pregnancy before they were induced, so up to a month past your due date, which is almost unheard of today. At around 41 weeks, people who agreed to be in the study were either randomly assigned to have an induction of labor or fetal monitoring with expectant management.

In the induction group, labor was induced within four days of entering the study, usually about 41 weeks and four days. If the cervix was not ripe and if the fetal heart rate was normal, they were given a prostaglandin E2 gel to ripen the cervix. They used a maximum of three doses of gel every six hours. If this did not induce labor or if they did not need the gel, people were given IV oxytocin, had their waters broken, or both. And they could not receive oxytocin until at least 12 hours after the last prostaglandin dose.

So one strength of this study is that it had a defined induction protocol that providers could replicate. But the big weakness of this study is that the expectant management group did not have that same induction protocol. In the monitored or expected management group, people were taught how to do kick counts every day and they had a non-stress tests three times per week. They also had their amniotic fluid levels checked by ultrasound two to three times per week. And labor was induced if there were concerning results in the non-stress test, or if there was low amniotic fluid, or if the mother developed complications, or if the person did not go into labor on their own by 44 weeks. And if doctors decided the baby needed to be born, mothers in expectant management group did not receive any cervical ripening. Instead, they either had their water broken and/or IV oxytocin, or they just went straight to a cesarean without labor. So Anna, do you want to talk a little bit about what the researchers found in the study?

Anna Bertone:   What the researchers found in the Hannah post-term study is that in the induction group, 66% of the people were induced and 34% went into labor on their own before induction. And in the expectant management group, 33% were induced and 67% went into labor on their own. There were two stillbirths in the group assigned to wait for labor and zero in the group assigned to induction. This difference was not considered to be statistically significant, which means we don’t know if it happened by chance or if it was a true difference between the groups. The more interesting outcome to look at with the Hannah post-term trial are the findings on cesarean rates because they differ depending on what numbers you look at. You can either look at the outcomes for the two original groups, which were the people randomly assigned to induction and then those assigned to expectant management, or you can look at the breakdown of what actually happened to the people in the two groups, in other words what happened to the people who were actually induced or who actually went into spontaneous labor.

Anna Bertone:   So what happened in the original randomly assigned groups? If you look at the two original groups, the overall cesarean rate was lower in the induction group. It was 21.2% versus 24.5%. That was even after taking into account factors like the mother’s age, whether or not it was her first baby, and cervical dilation at the time of study entry. Or you could look at what happened with the people who were actually induced or who actually went into labor on their own. And if you look at that, you see two very interesting things. You see that people who went into spontaneous labor, regardless of which group they were assigned to, they had a cesarean rate of only 25.7%. But if people in the monitoring group had an induction, their cesarean rate was much higher than all the other groups. It was 42%. The same was true for both first-time mothers and for mothers who had given birth before.

Anna Bertone:   So what does this mean? It means that only the people who were expectantly managed but then had an induction had a really high cesarean rate. The people who were expectantly managed and then went into labor spontaneously did not have a higher cesarean rate. One possible reason for this, for the highest cesarean rate seen in the people who were assigned to expectant management but then ended up getting an induction, is that the people in this group might’ve been higher risk to begin with since a medical complication could have led to their induction. The people that were assigned to expectant management and never developed a complication requiring an induction, those were the lower risk people, which means they were the ones less likely to end up giving birth by cesarean.

Anna Bertone:   Then, another important factor that I know Rebecca has discussed previously is that doctors might’ve been quicker to call for a cesarean when assisting the labors of people with medical inductions if their pregnancies were beyond 42 weeks. They may have been less patient waiting for labor.

…Or more easily worried about the course of the labor, big baby, etc. – 

Anna Bertone:   Yes. More worried.

So basically, it seems like from the Hannah post-term trial, one of the benefits of considering expectant management is that if you do have spontaneous labor, your chance of cesarean is pretty low. But the risk is that you’ll develop medical complications and need an induction, in which case an induction at 42 weeks is going to be riskier than an induction at 41 weeks. So what do you think? We have all this research from all over the world, from the Hannah post-term trial, to the 2018 meta-analysis, to two trials out in 2019. Do you still feel like routine induction at 41 weeks is still going to be controversial or not?

Anna Bertone:   I think it’s definitely still controversial, and I think everybody’s still processing the results from the INDEX trial and the SWEPIS trial. Rebecca and I reached out to Dr. Wennerholm who conducted the SWEPIS trial in Sweden, and she said she’s currently working on secondary analysis of the data. They’re talking about the economic implications of the findings in Sweden and what it means for Swedish national policy. So I think it’s still controversial. People are still talking about what to make of these findings.

Anna Bertone:   There was another systematic review from 2019 by Riedel. This one came out too early to include the SWEPIS and the INDEX trials, but it’s still interesting to look at. Because unlike the Middleton Cochrane review, these authors were specifically interested in induction during the 41st week of pregnancy versus during the 42nd week of pregnancy. So in their analysis, they restricted the studies only to people having a routine induction at 41 weeks and zero to six days versus routine induction at 42 weeks and zero to six days. If you remember, the Cochrane review was much broader than that. They also only looked at studies published within the last 20 years. They only looked at studies with low-risk participants, and they ended up with three observational studies, two randomized controlled trials, and two studies that they called “quasi experimental studies”, which they grouped with the randomized controlled trials even though these studies weren’t truly randomized.

Anna Bertone:   What they found was one perinatal death in the 41 week induction group and six deaths in the 42 week induction group. That was a rate of 0.4 versus 2.4 per 1,000. This finding was not statistically significant. In other words, we don’t have strong enough evidence that this couldn’t have happened by chance. These same studies, those two randomized controlled trials and the two quasi experimental studies, they showed no difference in cesarean rates between groups also. But the authors did report that one observational study found an increase in the cesarean rate with the 41 week induction group. So basically, they’re saying if you look much more narrowly at the evidence of induction during the 41st week versus the 42nd week, then there might not be a significant difference in the death rate.

But that Riedel study from 2019 is already outdated because that was before the two big randomized trials came out.

Anna Bertone:   Yes. We need to see a systematic review and meta-analysis that includes those two randomized controlled trials and see if that changes. These authors also expressed concerns about the cesarean rate possibly rising with 41-week induction because both the SWEPIS trial and the INDEX trial took place in countries with very low cesarean rates. So we just don’t really know at this point whether there would be a difference in cesarean rates if they took place in countries with higher rates of cesarean, such as the U.S.

Anna Bertone:   So I think it is still controversial. There’s also countries that are changing their policies about induction and going back and looking at whether that policy change led to any difference in outcomes. One such country is Denmark. They just published a study where they compared birth outcomes from 2000 to 2010 versus 2012 to 2016. And in that time period there was a change in policy from recommending induction at 42 weeks and zero days to 41 weeks and three to five days. They included over 150,000 births in the dataset. And when they looked back, they didn’t see any difference in stillbirths, or perinatal deaths, or low Apgar scores when they compared the period before versus after the policy change. The perinatal death rate was already declining before the policy change in 2011, and it just continued going down without any additional impact from the 2011 policy change. There was also no impact on the rate of Cesareans with the policy to switch from 42 weeks to 41 weeks.

Anna Bertone:   That’s just an example of how this is still controversial. Countries are implementing new policies, and Sweden and the Netherlands may implement new policies based on the INDEX and the SWEPIS studies. Then they’ll probably conduct a study the same way that Denmark did to see if that policy change had any real impact on the population.

I think it’s important to mention, though, that with the Denmark national policy, they switched from 42 weeks and zero days to 41 weeks and three to five days, and that might not have been early enough to make an impact on the stillbirth rate because the studies that we were looking at from 2019, SWEPIS and INDEX, were looking at inductions happening at 41 weeks and zero to one or two days and it was that couple of days difference that made the difference between low stillbirth rate and a higher stillbirth rate.

Anna Bertone:   Right. Exactly. I think that future researchers shouldn’t group 41 weeks and zero to six days together in one grouping because there seems to be differences between the earlier part of the 41st week and the later part of the 41st week because, like you said, SWEPIS and INDEX found that waiting even just two or three days make a difference in outcomes during that week.

So let’s just sum up the pros and cons of induction at 41 weeks versus continuing to wait for labor since that’s what we have the bulk of the evidence on now. I would say that the research shows that the pros of inducing labor at 41 weeks include a lower risk of stillbirth, especially among those with risk factors for stillbirths such as being pregnant with your first baby. In our article, we have a table of the pros and cons. The absolute risk of stillbirth is 4 out of 10,000 pregnancies at 39 weeks, 7 out of 10,000 pregnancies at 40 weeks, 17 out of 10,000 pregnancies at 41 weeks, and 32 stillbirths out of 10,000 pregnancies at 42 weeks. Research also shows a lower risk of the baby receiving intensive care with an elective induction at 41 weeks, lower risk of the baby having jaundice, lower risk of the baby being large for gestational age, and lower risk of needing a cesarean, although that finding may depend on your practice setting. There is a lower risk of mother developing a high blood pressure disorder. at the end of pregnancy. And for some people, they may find an elective induction at 41 weeks convenient and it could help them end an uncomfortable pregnancy.

Also, in our article, we reference one study that found some cognitive benefits for babies. It suggests that the cognitive benefits for the baby from the mom remaining pregnant appear to increase until about 40 to 41 weeks after which there’s no cognitive benefits to the baby’s brain development for continuing to remain pregnant. So Anna, can you share the cons of elective induction at 41 weeks?

Anna Bertone:   Yeah. One of the cons of being induced at 41 weeks instead of continuing to wait and see if you go into labor is the potential for medicalization of birth. One example of this is continuous fetal monitoring may occur if you have the induction, whereas you might not get continuous fetal monitoring if you go into labor on your own spontaneously during that 41st week. 

Anna Bertone:   Another con would be a potential for failed induction leading to a cesarean. That also depends a lot on your practice setting. Another con is the potential for uterine tachysystole, which is defined as more than five contractions in 10 minutes averaged over 30-minute window. There’s a potential increase in the risk of uterine rupture with medical induction. That is especially important among people with a previous cesarean having a VBAC.

Anna Bertone:   Another con is missing the hormonal benefits of spontaneous labor. Another con is increased risk of mother getting inflammation of the inner lining of the uterus, endometritis. One study found that as a possible risk of induction 41 weeks. Then, lastly, medically-induced contractions might increase pain and make epidural use more likely.

We also have a section in the article where we talk about whether there are any benefits to going past your due date. That table we just took you through was comparing the benefits and risks of elective induction. In terms of benefits of going past your due date, one of the major benefits of awaiting for spontaneous labor are the hormonal benefits, which Anna briefly mentioned. In our article, we link to the book Hormonal Physiology of Childbearing by Dr. Sarah Buckley, which talks about the physiologic understandings and the physiology of spontaneous labor. So that is something to keep in mind, and that’s one reason why some people prefer to wait for spontaneous labor. So Anna, if someone wants to wait for labor to begin on its own and they’re talking with their care provider about expectant management, what’s kind of the bottom line about that?

Anna Bertone:   I think the bottom line about that is it all needs to be very individualized. When someone goes past their estimated due date, they could talk to their care provider about the benefits and the risks of elective induction versus continuing to wait for labor and how those benefits and risks apply to them personally. Most research articles and guidelines say that because there are benefits and risks to both options, the pregnant person’s values, goals, and preferences should play a part in the decision-making process.

Anna Bertone:   It’s important for expectant families to be aware of the growing research evidence showing that there could be worse health outcomes for those who wait for labor after 41 weeks of pregnancy instead of being induced at 41 weeks, especially among first-time mothers and those with additional risk factors for stillbirth. But ultimately, after receiving accurate evidence-based information and having conversations with their care providers, pregnant people have the right to decide whether they prefer to induce labor or wait for spontaneous labor with appropriate fetal monitoring.

I want to also let people know about a couple more resources that are in this article at evidencebasedbirth.com/inducingduedates. We have a section all about how people and their care providers can talk about the risk of stillbirth with some sample scripts that healthcare providers can use when they’re talking about risks of stillbirth. We also have links to different guidelines from different organizations about induction at 41 weeks. Then we also have our section called The Bottom Line. So what would you say are some of the bottom lines, Anna, about elective induction at 41 weeks and zero to two days?

Anna Bertone:   I think the bottom line is that elective induction at 41 weeks and zero to two days could help to reduce stillbirths and poor health outcomes for babies without increasing harm, like the risk of Cesarean for mothers. We’re getting that from those two large randomized controlled trials published in 2019 that both found benefits to elective induction at 41 weeks instead of continuing to wait for labor until 42 weeks. One of those studies, as we mentioned, found less perinatal death with 41 week induction and the other found fewer poor health outcomes for babies like intensive care unit admission and low Apgar scores with 41 week induction. Neither of those trials found an increase in the risk of Cesarean during birth with 41 induction compared to continuing to wait for labor until 42 weeks. However, both of those trials took place in countries that follow the midwifery model of care and the overall Cesarean rates were very low. So I think it remains to be seen how that will translate into countries like the U.S. that have higher Cesarean rates. 

So I hope you all found this podcast helpful in looking at the recent research on induction at 41 weeks versus expectant management. Make sure you check out the blog article that goes along with this podcast episode for all of the resources, links, research references. We also have a free one-page handout you can download that summarizes the results of this research. Just go to evidencebasedbirth.com/inducingduedates to download that new article. Thank you so much, Anna, for joining us to help our listeners understand the evidence.

Anna Bertone:   Happy to do it, Rebecca. Thank you.

Today’s podcast was brought to you by the PDF library inside the Evidence Based Birth Professional Membership. The free articles that we provide to the public at evidencebasedbirth.com and this free podcast as well as other resources are supported by our Professional Membership program. Everyone who joins our professional membership gets access to a library with all our printer-friendly PDFs. Each signature article that we publish online has been turned into a professionally-designed, easy-to-print PDF so that our members can print and share evidence-based info with their clients, other parents, or other professionals. To learn how you can become a member today, visit ebbirth.com/membership.

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Special screening of BBC series ‘This Country’ coming to Gloucestershire and tickets are completely free – Gloucestershire Live

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For fans of the Cotswold based hit TV show ‘This Country’ you could be in for a treat.

BBC Three is bringing the series back to its Cotswolds roots on January 23 – and tickets are completely free.

Fans will get to see the first two episodes of the new series followed by a Q&A with sibling stars Daisy and Charlie Cooper, producer Simon Mayhew-Archer and director Tom George.

Coming back to its Gloucestershire roots on January 23 in Cirencester the special screening will be hosted by BBC Points West Gloucestershire reporter Steve Knibbs.

Tickets to the event at Bingham Hall, Cirencester , will be allocated though a random ballot.

You can apply for tickets from 10am on January 3 to 10am on January 10.

Charlie Cooper otherwise known as ‘Lee “Kurtan” Mucklowe’ said: “We are so excited to have the screening of series three here in our hometown Cirencester , where the show was created.

“Some would call it a homecoming but the problem is we’ve never left. Big up the Cotswolds !”

This Country follows cousins Kerry and Lee ‘Kurtan’ Mucklowe through their quiet country lives.

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At the 2018 BAFTAs This Country won the award for Best Scripted Comedy and Daisy won Best Female Comedy Performance. More than 33 million people have requested the show on iPlayer.

The new series airs in early 2020.

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Stephanie Marshall, Head of the BBC in the West and South West, said: “We love bringing national series like This Country back to where they were made. It’s a way of thanking people in the area by giving them a sneak peek before the rest of the UK.

“Amazingly more than 4,000 people applied for tickets to the This Country screening last year.

“The BBC is committed to make more and more of its TV, radio and online content outside of London. In fact, more than 50 per cent of all our shows are now made outside of the capital.”

To apply go to the BBC Shows and Tours website here .

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Philip Glass Is Too Busy to Care About Legacy – The New York Times

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If that’s true, it won’t be until nearly 2100 when a full measure of Mr. Glass’s footprint will be possible. But some weighing can start now. The most instantly recognizable voice in contemporary music, he opened a new chapter in operatic history, pushing the bounds of duration and abstraction. At a time when the most lauded composers disdained overproduction, Mr. Glass wrote unashamedly for everyone and everything — and all stubbornly in the distinctive style he created, establishing a model for serious artists moving from the opera house to the concert hall to the film studio, garnering both Met commissions and Academy Award nominations.

MR. GLASS WAS BORN, almost literally, into music: His father owned a record store in Baltimore, where the composer-to-be absorbed Beethoven, Schubert, Bartok, Shostakovich and Stravinsky — and, perhaps, an intrinsic connection between art and commerce. Over a few years in Paris, Nadia Boulanger was his composition teacher as he was exposed to the jittery-fly modernism of Boulez and Stockhausen. He didn’t hate them, but he didn’t want to compose like them, either.

Those pieces culminated in “Einstein on the Beach,” a dreamlike meditation on scientific discovery, human relations and nuclear apocalypse that progressed in enigmatic episodes, austerely designed and directed by Robert Wilson and with swirling choreography by Lucinda Childs, the dancers representing atomic particles in ceaseless motion.

“When ‘Einstein’ opened,” Mr. Glass said, “we had never performed it straight through without stopping. We didn’t know how long it was. It turned out to be five and a half hours.”

Mr. Glass became a maestro of excruciatingly delayed gratification. “I have no idea what Philip was thinking when he wrote ‘Satyagraha,’” Mr. Guérin said of that 1980 opera, a highly stylized but (compared with “Einstein”) more traditionally plotted story about Gandhi’s early ventures into nonviolent protest in South Africa. “The third act is 45 minutes long, and has just two harmonies. But when it explodes into pure Phrygian scale in the final aria, it’s, like, oh, this totally makes sense.”

When it came to “Satyagraha” and “Akhnaten” (1983), Mr. Glass said, “many people were waiting for the son of ‘Einstein.’ They liked that experience of that throbbing, relentless ensemble playing that we did. Of course I wasn’t going to do that. Why would I do that? I had just done it. So I did something completely different, and it was much too lyrical for some people.”

The bronzed character of the “Akhnaten” score emerged through necessity. The company in Stuttgart, Germany, that commissioned the work was renovating its theater, so the performances took place in a space with a much smaller pit.

With the violas now taking the place of the violins, the sound shifted down an octave, its burnished sheen given body with brasses and punctuated by sometimes raucous percussion. As for the title character, the Egyptian pharaoh who is said to have pioneered monotheism — and to have had all traces of him erased for that blasphemy — Mr. Glass put him onstage from almost the beginning, but tantalizingly delayed his first musical entrance.

“How do I introduce him to the audience so that the first time they hear him, they understand he is a completely radical, unforgivable event in the Egyptians’ history, and they have to destroy him?” Mr. Glass recalled asking himself. “I’ll make him a countertenor, to sound not unnatural, but radical. Radical can be natural. He just was who he was.”

“The world had caught up with his music,” Mr. Guérin said. “The Philip Glass sound became digestible to mass audiences. If you had told the people in New York that the composer of ‘Music in Twelve Parts’ would be able to maintain his musical language and score major Hollywood pictures, they wouldn’t have believed you. But he got to be himself.”

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See is a funny TV show, but not on purpose – The Verge

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There’s a scene in See I would bet everything in my wallet (seven dollars, three old MetroCards, and five half-used coffee rewards cards) that it’ll go viral. It’s the one where Jason Momoa’s character picks up a book for the first time. Since the show is set centuries after a virus deprived humanity of sight, he has no idea what’s in his hands. He complains it smells like “dead bark” and holds it the way a toddler might hold a vegetable when they were in fact expecting a cookie. Then Alfre Woodard’s character demands he hand over what he’s found, and speaks its long-forgotten name: book.

It’s extremely funny in context, and probably debilitating out of it. It also makes See, Apple’s post-apocalyptic drama, one of my favorite kinds of shows: you could just plainly state something that happens in an episode, and everyone would swear you’re making it up. That doesn’t mean you should watch it.

Set in the ruins of our world, the people of See have adjusted to a sightless life after centuries of practice. Makeshift curtains of beads make for boundaries both audible and physical, fights involve a lot of probing contact and grappling (as does sex), and there’s a lot of finger snapping. See is extremely invested in showing you how all this stuff works, so much so that it barely delves into its characters.

Baba Voss (Jason Momoa) is a man who must take his family on the run after his adopted twins, Kofune and Haniwa, are born with sight. The trouble is, the very idea of sight is heretical — much like witchcraft in colonial America, troublesome people are accused of having the ability to see as justification for burning them alive. And there’s also an evil queen who learns of the twins, and as a religious zealot who worships the “darkness” (by, and I will testify to this in court if I have to, masturbating as she prays) she wants them brought to her for evil queen reasons.

A generous and forgiving read of See could interpret it as an attempted meditation on knowledge, ignorance, and responsibility, but See actively resists attempts to latch on to anything of substance it might have to offer. In the first three episodes made available in advance to critics, See is more interested in the logistics of its world than it is in implications.

Sometimes that leads to fun television. The third episode, the best of that initial bunch, is largely unconcerned with the season’s main arc, instead telling a story where Kofune is kidnapped by slavers and must be rescued. It’s visually striking, introducing a tribe of people that, unbeknownst to them, are living in the ruins of an amusement park. It’s got a killer fight scene, with unique choreography that clearly conveys the limitations and skills of everyone involved and depicts brutal violence with grace and skill. And it’s got personal stakes, which I won’t spoil here because it’s one of the only bits of character backstory you get in the first couple of episodes.

None of these things make See a more interesting show beyond the hour you spend watching them. It’s cotton candy, a fun confection for one moment, and just plain sugar the next.

See is clearly interested in drawing people into its elaborate and well-crafted post-apocalypse, but it’s telling that the only questions I have after watching are purely pedantic ones. Like how did a blind society make such perfect and deadly weapons, or build homes that never leak, or clothes and makeup that look so nice?

These are questions asked by jerks and spoilsports, and I wish I had better ones to ask of See. The show is strange, but fails to justify that strangeness with a compelling story, characters, or literally anything other than the list of ideas you and your stoned cousin would come up with if you wondered what it would be like if we all woke up one day totally blind, man. Maybe you’ll come up with something fun enough for posting on Twitter, but it’s not going to cut it for eight hours of television.

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Forget Succession, Because Watchmen Has ArrivedAnd It Is GOOD

This is a preview of our pop culture newsletterThe Daily Beasts Obsessed,written by senior entertainment reporter Kevin Fallon. To receive the full newsletter in your inbox each week,sign up for it here.

Youre Going to LoveAnd Be So Confused ByWatchmen

Remember when everyone was like, Whats going to happen to HBO when Game of Thrones ends? And, like, Is TV dead as we know it?

I mean, I guess its understandable to want to stage a funeral for great television while watching that final season of Thrones. (Burn!) But two drama series have aired on the network in the time since Kings Landing fell, each of which I would rank leagues above Thrones on any year-end Best of TV list: Years and Years and the second season of Succession.

The former found a near-miraculous way to be topical about todays rabies-ridden sociopolitical discourse, while the latter took the mantle when it comes to watercooler buzz and, especially, with media and Twitter obsession. In addition to those two, the second season of Big Little Lies was a major ratings and press boon.

But with Watchmen, theres not just a third drama series of excellence entering the mix, but one that I think will, if not quite have the same reach as Thrones, fuel a fanbase of people who just will not stop talking about it.

Watchmen premieres Sunday and shares two unmistakable characteristics with that show: It is visually astonishing, with each frame more ambitious, stunning, and remarkable than the one before. You also have no idea what the hell is going on at any given moment. If you liked that about Game of Thrones, youll LOVE it about Watchmen.

That a series which poses such a fascinating narrative conundrum would count Damon Lindelof as its creator should come as no surprise; as the man behind Lost and The Leftovers, hes proven a penchant for a certain kind of dazzling befuddlement that evolves into brilliance. The series is an adaptation inspired by the revered DC Comics 12-part series from writer Alan Moore and artist Dave Gibbons, but which the HBO creative team involved refers to as more of a remix.

I have not read the comic series, so I have no idea what that means, but I can say that I didnt feel like I needed to have read it to enjoy the episodes of the HBO show that I watched. I also saw the notoriously maligned 2009 Zack Snyder film adaptation, but dont remember anything about it besides its insane sex scene: as Patrick Wilsons legendary bottom thrusts and a fully-nude Malin Ackerman gyrates, Leonard Cohens Hallelujah plays.

Anyway, what I am getting at is that you dont need to be familiar with these things to watch the show.

The show itself presents a sort of sci-fi alt-history, set in a contemporary America where Robert Redford is serving the longest presidential term in history. He has signed into law reparations for black Americans. Vietnam is a state. Things are…different. But as a jolting reminder of how not-different things are, or at least have been through history, the series starts with a violent, brutal dramatization of the very real 1921 Tulsa massacre, in which as many as 300 black citizens were killed.

That real history haunts the shows alt-history, where, in the present day, white supremacists are hunting down police officers. These officers now wear masks to conceal their identities for their own safety, and are working alongside masked vigilantes, like Regina Kings Sister Night, who is a former cop named Angela.

Theres a lot to say and untangle about the ties between white supremacy and institutions like the police force, as well as the very ideas of policing and justice in general, which are coming untethered among escalating racial tensions. What lands and what doesnt land is subjective in Watchmen, and you cant shake the feeling that you need to watch the series unfold entirely before ruling one way or the other.

Of course, the journalists and critics (hi!) telling you to watch this because its really damn good have had the luxury of seeing six full episodes. Id go ahead and comfort you by saying if youre intrigued enough by all of the huh? in episode one, you get many answers in episode twothough, my god, not all, not even close. Quote Kings Angela after a particularly baffling, though thrilling, moment: What the fuck?

Same, girl. And often. But by the time Jean Smart enters in episode three, you know I was on board, full-stop. She gives one of my favorite performances of the year as a former superhero-turned-FBI agent, a perfect complement to my nightly bingeing of her work as Charlene Frasier on Designing Womena TV series I have mentioned in this newsletter far more often than I really should.

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Will X Factor Celebrity improve the show’s ratings?

It’s the time of year again where your TV guide fills up with more late-night entertainment.

ITV’s The X Factor used to dominate the weekend ratings with its sometimes harsh auditions and names like Beyonce and Rihanna at the live finals.

But over the years, the show’s figures have dropped to less than half of what they were in 2010.

The first episode of the celebrity edition aired on Saturday, with 4.71 million viewers.

The X Factor reached peak viewing figures in 2010 when, according to the Broadcasters’ Audience Research Board (BARB), episodes averaged more than 14 million viewers in the UK.

Last year’s series, won by Dalton Harris, averaged roughly six million viewers, so last night’s figures of five million aren’t a great start for the series.

The format is simple, celebrities who are already known by the public, but not for singing, compete to impress judges Simon Cowell, Nicole Scherzinger and Louis Walsh.

The line-up caters to a range of ages, including everyone from Love Island stars and social media influencers, to broadcast journalist Martin Bashir.

newsSpeaking last week at the show’s launch on Thursday, original judge Louis Walsh told Radio 1 Newsbeat: “It needed something different.
This is a whole new chapter and I think it’s the future for X Factor.”

 

The first episode, showing auditions in front of various music producers and writers in Simon’s garden in Malibu, received mixed responses online.

The format is far from the small, minimally designed audition room with an X on the floor from early series’, but the judges haven’t changed much.

Reality star Megan McKenna told Newsbeat: “I was so happy when I found out it was judged by Simon, Nicole and Louis because they’re the originals.

“I’ve watched the show growing up my entire life, so singing in front of them was one of the best moments of my whole life.”

BBCDermot O’Leary will once again host the series and be the contestants’ general shoulder to cry on.

He said: “It may well be that we uncover this incredible singer, it may well be that it doesn’t fly – but it’s definitely worth the risk.

“Whether we can find a recording artist with these celebrities – probably not! As long as we can put on a good entertainment show, that’s what matters.”

Nicole agreed that the show was more about providing entertainment, saying: “We still get pretty great ratings, all we can do it put on the best show we can, and hopefully we can entertain the people who are watching.”

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How ‘The Good Place’ made the cast, creative team and maybe even the viewers better people

creative team and maybe even the viewers better people - CNN

(CNN)“It felt a little bit like what I imagine sending your kid off to college feels like,” says Kristen Bell about wrapping up “The Good Place,” currently in its fourth and final season on NBC. “It’s a good and bad feeling.”

“I refuse to spend my final moments being allowed to play with these people in misery — I think that would be pitiful,” says Bell. “I didn’t want to let that ruin it, because it is a gift. It really does feel like we did it for a reason, and when you see the ending you’ll know.”
When the finale comes, it will mark the end of a long, always fitfully funny but also moving journey of striving for enlightenment and self-betterment in the afterlife of a group of damned souls — Eleanor (Bell), Chidi (William Jackson Harper), Tahani (Jameela Jamil), Jason (Manny Jacinto), plus the reforming demon Michael (Ted Danson) and the ultimate Siri/celestial automaton Janet (D’Arcy Carden). It’s meaty philosophical, territory peppered with silly swear word substitutes.
    “I definitely felt the anxiety of landing the plane more acutely than in previous years,” the show’s creator and executive producer Michael Schur tells CNN. A veteran of “The Office” and “Parks and Recreation” — two series both riotously funny and deeply warm-hearted which also struck pitch-perfect notes as they concluded — Schur admitted his team sweated many details crafting “The Good Place’s” endgame. “We spent a massive amount of time on the ending. Because we really wanted to get it right,”
    “I feel like we had a fairly good handle going into it, where our end point was,” says supervising producer and writer Jen Statsky, who explained that the series’ creative team constantly took a “forward-thinking” approach to the way the story unfolded season by season, neatly set up the story and character arcs to play out in subsequent episodes, which paid off as the final season was conceived. “You want to give the proper ending to these characters.”
    “And to make sure that we had covered all the ground we wanted to, and to be like, ‘Did we explore every facet of these characters and of the world?'” adds co-executive producer and writer Megan Amram, nodding to the rich, comic afterlife mythology the series has constructed. “In some ways we’ve been talking about the ending of the show almost since we started writing the show.”
    Thus the decision to end after four seasons, on their own terms, at a moment in time where broadcast networks tend to mine hit series for as long as they possibility can. When it became apparent that the fourth season would lead to the most organic and satisfying conclusion, NBC deferred to Schur’s creative vision. “We knew why [it was time to end], and it was because of the meaning of the show and it was because we were telling story that deserved its ending,” says Bell.
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    As the cast and crew delved into the many ethically and morally thorny issues the show’s characters would have to contend with, they found themselves in an extended learning curve as they routinely consulted academic experts in fields such philosophy, neuroscience and criminal justice to bring nuance and context to the series. “We’ve learned so much about so much stuff,” says Schur. “It’s been like a rotating course of lectures that we’ve had in our writers room, and it’s been so fun.”
    “We’ve all been very lucky to work with various writers rooms before, but this is the first one that felt like a combination writers room/college course,” agrees Statsky. “And for a true dummy like myself, it’s been very enjoyable to just not only get to be at work, but get to be learning about these topics that I had no previous knowledge of.”
    “This is paying us to go to college,” laughs Amram.
    Bell says that by exploring such heady, meaningful topics, even through a comedic lens, had a profound effect on everyone involved in the show, leaving everyone considering seriously what it meant to make a positive impact, both on those around them and on a global scale.
    “There are these opposing theories in my head about ways to be, to state my opinion fighting for good or do it with my art, and I vacillate between the two,” says the actress. “This was one where I felt like I really did it with my art, where I was a part of saying some things that I wanted to put out in the world, and I was really lucky to be able to be offered a job that was both creatively fulfilling and emotionally fulfilling to my sort of maternal instincts towards the world…I hope to get both again, but this is a pretty lucky experience.”
    The show’s conceit, to strive to be better even in the face of eternal damnation, proved downright infectious.
    “In the fabric of the show we talk about, life is a lot of little choices,” says Amram. “The show helped me realize that going through my day, I am presented with a lot more moral decision-making than I had previously thought. And I try to always make this slightly better choice now. And I think that is what the show is about. It’s like, when presented with two things, think about it, and maybe try to make the slightly better choice.” As a result of her involvement on the show, for example, Amram committed to a vegetarian lifestyle.
    “I don’t think that I totally understood the level of which moral decision making can become a factor in your life, where from the moment you wake up to the moment you go to sleep almost everything you do has a moral component,” says Schur. “It can drive you nuts. I’m not necessarily saying this is a good thing.”
    “We do it when we order lunch and when we have any big decision to make. You can get really paralyzed,” adds Schur, noting that the show used the character of Chidi and his inability to resolve micro-ethical considerations to illustrate the point.
    How 'The Good Place' made the cast
    “If you let the idea of making a moral decision infect your life to that level, you become a nonfunctioning human being,” he adds. “The important thing is that you think about it, and then the next most important thing is that you are okay with the idea that you’re going to blow it sometimes…You need to let yourself off the hook when you do things that aren’t exactly perfect.”
    It’s a quandary that resonates deeply for the actor who brings Chidi’s indecision to life.
    “A lot of that is a very intuitive manifestation of a lot of my own stuff,” says Harper. “Maybe it’s more universal than I thought. Maybe a lot of people feel that way, but I personally get stuck a lot, and I think that just seeing what that paralysis looks like can actually be freeing, because sometimes it’s really useful to see it from the outside, the commitment to an action or inaction, how frustrating that can be. Especially to someone who is like, ‘Any choice you make right now will be better than not making one’… The most salient thing about the show and especially about this character for me is that.”
    Harper says that as a result of being a part of “The Good Place,” on screen and off, he couldn’t resist a powerful impulse for self-improvement.
    “I’ve learned in a very visceral way that people make the world, and the world that we are so privileged to inhabit for these past four seasons is beautiful, and wonderful, and full of good feelings and positivity and kindness,” he says. “And there’s no way to have that environment at work and not feel like, ‘Well, why can’t this be what the rest of my life is like?’ So coming away from the show, I want to make sure that I try to put as much good into the world as I can going forward.”
    Much of that is a result of the people Schur invited in to “The Good Place’s” world, says Stasky.
    “Mike’s an expert picker of people to work on projects. He has a very good radar for good people who want to make good things and treat each other well in the process of making those things. He empowers people to feel like they are a part of the project, and that really I think creates this environment where everyone is just happy, they’re happy to come to work, they feel they have a stake in it, and it’s a fertile ground for relationships to grow.”
    Indeed, as the public face of the show, the cast has demonstrated an emotional investment in both “The Good Place” and one another that’s rare among even the oft-self-proclaimed “families” of other TV series. A recent panel at the Television Critics Association’s press tour found the actors all tearing up as Danson waxed poetic about what a gift the series had been to them. And the show’s fans are likely to have similarly intense feelings about its departure.
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    But will it have a lingering effect on the way its viewers choose to impact the world?
    “I am extremely wary about ascribing success or failure to the show in any goal,” says Schur. “People used to ask if I felt like ‘Parks and Recreation’ had convinced people that government could be good or something.”
    “The only thing you can ever do is you can be very specific about what the show is saying. You can’t force people to hear the message or to react to it in any specific way,” he continues. “I don’t know whether people engage with the show purely comedically, or whether they engage with it spiritually, or academically, or whatever. I don’t think you can ever hope to control that. You can only say, ‘Here’s the thing: now it’s yours. You can react to it however you want.’ And we certainly have hopes that that’s true, but I don’t think there will ever be a meaningful way to gauge that.”
    Harper, however, offers anecdotal evidence to suggest otherwise.
      “I remember this one time there was a woman on a train who recognized me from the show, and we started crying,” he says. “I feel like there’s a real desire for people to see other people being good to each other, especially where we’re at right now in the country where it just doesn’t feel like that’s happening very much.”
      “It gives you hope that this is something that is possible, that there’s someone out here that’s thinking about these things, and putting it on television for people to watch.” Harper adds. “It must be comforting for people to know that people like Mike Schur exist.”

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      Tom Green Has One Big Regret About Drew Barrymore and SNL

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      Tom Green was never more famous than when he hosted Saturday Night Live on Nov. 18, 2000.

      Not only was his insanely popular talk show still airing on MTV, he was coming off a scene-stealing performance in the hit comedy Road Trip. Just weeks earlier, Charlies Angels, in which Green appeared opposite his new fiance Drew Barrymore, debuted at No. 1 at the box office.

      It was an amazing thing to have gotten to do it, Green says of his SNL experience, 19 years later, on this weeks episode of The Last Laugh podcast. However, he adds, I think if I could go back and do it again someday, I would do it a lot differently.

      When producer Lorne Michaels offered Green the chance to host that fall, the comedian insisted that his childhood friends from Canada, whom he had hired as writers on The Tom Green Show, come in for the week and help write sketches. I didnt understand the politics of Saturday Night Live, he says, acknowledging that SNLs writers at the time, including Mike Schur, who would go on to create The Good Place, future Oscar nominee Adam McKay and head writer Tina Fey, may not have appreciated the input.

      I was aggressively trying to deconstruct everything that I encountered, Green explains. Just because I was a kid in my twenties and I was like, thats the way you do it. Lets try to take it apart and put it back together upside down and inside out.

      I think in hindsight I would have rather just shown up and worked with everybody else and just kind of went with the flow a bit more, he adds. But I was young and passionate. Green says his friends ended up writing about half of the sketches that aired in his episode, including one in which he appeared in a bathtub with Lorne Michaels as well as his monologue and the final sketch of the night.

      Greens big idea for the episode was a gag that would be teased at the beginning of the show and pay off in the final moments. His relationship with Barrymore was all over the tabloids and he thought it would be funny if they appeared together during his monologue and announced they would be getting married on live television at the end of his SNL debut.

      I try not to have regrets, but that is something that I actually regret, Green says. So Drew and I actually were engaged at the time. So we thought, this will be a funny prank. Well prank the audience. Well tell everyone were going to get married on SNL and then she wont show up at the altar at the end and that will be the punchline. Even though we were still getting married, like a month after. That was the bit.

      But the thing I regret about that bit to this day, which Im actually sad about, to be honest with you, is that the way we wrote the bit, we kept teasing that we were going to get married at the end of the showshes out in the hallway in her wedding dress, my parents are there in the audience, he continues. And then at the end of the show, she doesnt show up. And the end of my SNL I have a meltdown on stage. And its a complete meltdown and the band stops playing and the entire cast disappears and Im just standing alone on stage at the very end of the show.

      Artistically, Green still thinks it was a pretty awesome way to end the show. But it does sort of ruin my beautiful Saturday Night Live kumbaya moment, he says. At the end of every Saturday Night Live, [the host] is hanging out with the cast and celebrating together. But on his episode, its just Green screaming I thought you loved me! on stage by himself.

      In some ways, its kind of a metaphor for the rebellious, naive kid that I was: Were going to go there and were going to try to turn SNL upside down! he says. But in other ways, I think it just sort of ruined my Saturday Night Live experience. He does add that he and Barrymore went to the after party with the cast and had a blast.

      Green maintains that it was one of the highest-rated episodes that season because of the prank. It was a massive success in that sense, because we did create a reason to stay up til the end, he says.

      According to a Variety item from that week, the cancelation of the wedding was sprung on Lorne Michaels only five minutes before the ceremony was to take place on camera and the show reportedly had a priest and City Hall license on hand. Caroline Kennedy, Tom Hanks, Rita Wilson, Gwyneth Paltrow, Cameron Diaz, and Harvey Weinstein were among the celebrities waiting backstage to celebrate with the newlyweds after the show.

      To put it in perspective how crazy his life was at that time, Green tells me that the morning after Saturday Night Live aired, he and Barrymore got on a plane to London to have dinner with Prince Charles at St. Jamess Palace for the royal premiere of Charlies Angels.

      Green sat next to Camilla Parker Bowles at the dinner and had a two-hour conversation about stuff like France and organic farming among other topics. Was it a real mouse? Prince Charles asked Green of the infamous scene from Road Trip in which he attempts to feed a snake and ends up putting a live mouse in his mouth. The answer was yes.

      Green and Barymore ultimately did get married in July of 2001 and were divorced less than nine months later. Green has called their marriage a crazy whirlwind of a time.

      So it was a bizarre time in my life, Green tells me. If he ever gets the chance to host SNL again, which would be nice, he says, I would love to be able to not bring my friends from high school in and not try to make it some crazy, warped episode.

      Nearly two decades later, the 48-year-old comedian chalks the whole thing up to the naivety of youth.

      I had been so hellbent on causing chaos everywhere I went that suddenly when I was where I was, I still was behaving as if I was living in my parents basement, Green says. I should have probably taken certain opportunities to just be grateful that I was there. And I didnt realize that at the time.

      Next week on The Last Laugh podcast: Stand-up comedian and star of ABCs Black-ish and Grown-ish, Deon Cole.

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      Controversial As It May Be, ‘Screen Time’ Makes Me A Better Mom

      Before I became a parent, I vowed to do (and not do) a lot of things. My daughter was going to be breastfed until she was 1, and she’d eat all-natural, organic, homemade meals. She would never use a binkie and would rarely touch a bottle. Screen time? She would be limited to 30 minutes a day. 

      Of course, my plan seemed fail-proof. I was 29 when I conceived my daughter: a work-from-home, stay-at-home mom. And my husband supported me. We agreed today’s kids were too distant and distracted. We were “those people,” the ones who judged the parents who broke out the iPads at dinner. Plus, we had read all the studies. Childless me knew best — or so I thought. Or so I believed. Until we had kids and “dinner dates” and things to do on our own.

      You see, it is easy to live in a disillusioned little bubble. Before children, I was smug. Scratch that: I was stupid and naive. And while I felt guilty, at least in the “early days” — the first time I used the television to distract my daughter, I felt like a bad parent; I convinced myself I was a “bad” mom — these days I believe the opposite to be true.

      Screen time makes me a better mom. 

      The first time I used the television to distract my daughter, I felt like a bad parent; I convinced myself I was a ‘bad’ mom — these days I believe the opposite to be true.

      Now I know what some of you might be thinking: That’s ridiculous. That’s absurd. Only crappy parents rely on Netflix and cable to care for their kids. Plus, the American Academy of Pediatrics strongly suggests parents limit media use. Kids under 5 should watch no more than 60 minutes each day, and those under 2 should watch no TV … at all. And while I do not dispute or refute the experts — these guidelines are in place for good reason — there are things science and studies fail to consider.

      My daughter is a Type A personality. She is high-strung, high-stressed and always on the go. She attends school every morning, dances almost every evening, and her weekends are spent running, both miles and errands. Some days I need to help her destress and decompress.

      Like most 6-year-olds, she gets worked up and “amped up” and watching a cartoon (or two) gives her a chance to shut off her mind.

      But there are other reasons — more selfish reasons — I let her watch TV. I am a stay-at-home and work-from-home mom. I have virtual meetings to attend and deadlines to meet, and giving her screen time gives me “me” time. I am able to write while she catches up on ”She-Ra,” “Sesame Street” and ”DC Super Hero Girls.” And while this may sound bad, at least on paper, I believe I am teaching my daughter responsibility. Through my actions, she knows women work. Hard. I am helping my daughter become more independent. When Mommy works, she gets her own snacks, drinks and toys, and I am teaching my daughter about balance. When the episodes are over, I’m done. I put my phone down and laptop away and we play.

      I am active, engaged and fully present.

      I am also calmer. News writing can be a fast-paced, demanding industry but setting boundaries — for her and me — has helped me unwind.

      I believe I am teaching my daughter responsibility. Through my actions, she knows women work. Hard. I am helping my daughter become more independent.

      There are other benefits, too. Television helps me talk to my child on her level. “Sesame Street” has spurred conversations about race, anxiety, diversity and disability. I’ve used Oscar the Grouch to explain that we cannot change another’s attitude but can love them in spite of it. He is also a key example of why you cannot (and should not) judge a book by their cover, and countless “Daniel Tiger’s Neighborhood” songs have worked their way into my home. I’ve found Daniel’s “When You Feel So Mad” song particularly useful.

      In short, television has opened dialogues between me and my daughter. Cartoons have helped me be more engaged with my kids.

      The TV has taught my daughter. Thanks to “Super Why,” she knew her alphabet at 2, and thanks (again) to “Sesame Street,” she was able to count to 20 by age 3. And I use the screen as a motivator. My daughter earns episodes or “tablet time” when she completes chores, e.g., making her bed earns 15 minutes while doing her homework gets her 30.

      TV time also gives us a chance to cuddle — something I fully appreciate as the mom of a high-energy kid — and to make memories. “The Nightmare Before Christmas” is a Halloween tradition, and we always spend Christmas week watching “Rudolph,” “Frosty the Snowman” and “The Grinch.”

      Television has opened dialogues between me and my daughter. Cartoons have helped me be more engaged with my kids.

      That said, I have a few “rules.” During meals, the TV is off. The dinner table is a screen-free zone. All programming must be supervised. I will not let my daughter watch a new series unless I can watch an episode with her first, and on weekdays, she is limited to two hours max, and that’s what works for me and my family.

      To each their own because I know better. I know not to judge other parents and how they parent. 

      So at the end of the day remember: It doesn’t matter what our kids watch or eat, it matters what they do, what they say, what they feel and how they act, and only you know what is best for them. Only you can decide what works for your family, your child and you.

      Have a compelling first-person story or experience you want to share? Send your story description to pitch@huffpost.com.

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      The Bachelorette Is The Worst Show On Television, So Why Do I Never Miss An Episode?

      I’m about to make a bold statement, so hold onto your hats!

      I love watching The Bachelorette.

      I already know what you’re thinking. Yes, I know it’s generally degrading. I know it makes otherwise good folks look like imbeciles. I know I’m being emotionally manipulated by myriad producers and editors whose sole job is to secure ratings. I know, I get it. But, ain’t ya ever heard of a guilty pleasure afore?

      Growing up, I watched only a handful of episodes from a couple seasons. I was first introduced to the show at 13, when I began to see Trista Rehn‘s face on the cover of every tabloid magazine at the grocery checkout. I remember being fascinated with the show’s concept. A bunch of dudes fight over one girl and then she has to pick her favorite ultimately making him the “winner.” But “winner” of what? Her heart? A game? Both? That sounds like fun!

      Thankfully, as a young adult, I didn’t waste my time being sucked into Bachelor Nation (the title given to super fans, ya know like Dead HeadsLittle Monsters, or Beliebers). No, as a young person I spent my time on more important things. (Like watching every episode of  and)

      It was until my mid-twenties that I officially joined the “Nation.” Now, the show has me dutifully plopped in front of a television set every Monday night.

      And I’ve done a lot of thinking and asked myself some pointed questions: Why do I love this show so much? Why do I look forward to Monday nights with such fervor? Why do I ignore the unrealistic message it’s sending to folks about relationships and love? Am I morally obligated to denounce the show in the name of feminism while saving my own dignity?

      While these are important and reflective questions to ponder, I already know the overarching answer is a blunt no. No, I won’t stop watching this show for the foreseeable future. But now, it’s time for my reasons…

      Why do I love this show so much?

      The simple answer (and arguably the most important): it’s entertaining. The folks who produce this show have gotten things down to a perfect science. They know exactly how to craft an episode or season’s trailer to leave you excited and salivating. Now, I’m not saying it’s great television. It’s trash. But like a crappy romance or dime-store novel, you just can’t help but turn the page. Or in this case, endure the commercials.

      Why do I look forward to Monday nights with such fervor?

      You know how folks love to get together for the Super Bowl? No matter who you are, how little you care about sports, or how much you hate Tom Brady, everyone LOVES to watch the Super Bowl. It’s a gathering. An excuse to get together with friends and family. A reason to pull out the old Crock-Pot and make Mom’s chili. A great opportunity to clink your beers and cheer on a team. Doesn’t matter which one, just pick a side.

      You see where I’m going with this… Monday’s are an excuse to get together with my girlfriends and sisters. Drink rosé and predict what might happen after the commercial break. Will the cocktail party be canceled tonight? Is Luke P finally going the f*$% home? Then there are all the mid-week, post-show convos. Are you all caught up yet? What did you think of Jed? Yeah, I’m free for lunch on Thursday!

      The Bachelorette is a really great excuse to hang out.

      Why do I ignore the unrealistic message it’s sending to folks about relationships and love?

      Let me rephrase this question: is it wrong for me to support a show that so inaccurately and unrealistically depicts relationships and love? I guess this question goes hand in hand with “Am I morally obligated to denounce the show in the name of feminism while saving my own dignity?” My answer to both is: no.

      But let me tell you a secret: THIS SHOW DOES NOT ACCURATELY DEPICT HOW HEALTHY RELATIONSHIPS FUNCTION!

      There. I said it.

      No, it’s not normal to date 30 people at the same time. No, it’s not normal to “need” to hear that someone “loves” you after 4 dates. And no, it’s not normal to truly and firmly believe that a man you’ve known for less than six weeks should propose to you. My biggest pet peeve with the show — other than repeatedly hearing Chris Harrison say “The most dramatic (insert noun) ever is about to begin!” — is how contestants seem to forget that other people exist on Planet Earth.

      “No!” they say, “I want THAT ONE!” And we all know that has to do with the chase and competitive nature of the show. It’s not so much that they’re in love with the Bachelor or Bachelorette, they really just want to win. And then, maybe they can go on to do something really great with their lives, like use Instagram to promote products they don’t even use themselves. FabFitFun codes for everyone!

      Here’s the thing, the people that decide to go on the show, know exactly what they’re signing up for. They know they’re going to get to meet cool people, grow their Instafollowing, travel all over, and hey, maybe they’ll get engaged to someone. If it’s truly real love, they’ll stick it out. If not, they’ll announce it in an Instagram post and then move on with their lives, FabFitFun commission check in tow.

      Oh and as far as my own personal dignity goes, I’m pretty proud of its current state and not watching a vapid reality show isn’t going to make me “better than anyone else.”

      Now, let’s all cross our fingers and hope Hannah B. picks Tyler C.

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