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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February 2020 restaurant inspections in Livingston County

February 2020 restaurant inspections in Livingston County

Jennifer Timar
Livingston Daily
Published 6:30 AM EST Mar 3, 2020

Of the Livingston County restaurants inspected in February 2020, priority and priority foundation violations were found at 29 locations. 

Each month, the Livingston County Health Department inspects some businesses and schools that serve food. 

The Livingston Daily publishes reports on the most serious violations — ones that could lead to contamination of food or increase the risk of transmitting a foodborne illness — as well as corrective measures taken.

Four priority violations were found at:

Hartland Sports Center

2755 Arena Drive, Hartland Township

There were three spray bottles not labeled as to their contents. The person in charge labeled the bottles properly at the time of the inspection. There was no soap at the hand sink. Soap was available upon the inspector’s return. There were no paper towels at the hand sink. A new shelf was not allowing staff to open the dispenser and refill. Upon the inspector’s return, there was a dispenser available and paper towels were stocked in the dispenser. There was no chlorine test kit available. The facility decided to use quaternary sanitizer instead.

Horseshoe Lounge

10100 W. Grand River Ave., Fowlerville

The dish machine was not dispensing the proper amount of sanitizer. It was suspected that the product was expired. A new container of sanitizer was added and proper sanitizer concentrations were restored. The hand sink in the main kitchen was soiled with food residue. Coleslaw and ranch dressing prepared on Feb. 3 were labeled with a discard date of Feb. 20. Foods that are time and temperature controlled for safety cannot be held more than seven days. A proper discard date label was attached at the time of the inspection. No detergent was being dispensed in the dish machine because the container was empty. A new detergent container was added at the time of the inspection.

RELATED: 15 most common restaurant violations in Livingston County

Three priority violations were found at:

440 W. Main Street, Brighton

A pan of cooked chicken wings was holding at 50 degrees in the grill line prep cooler. A container of coleslaw was holding at 46 degrees. Upon further investigation, other items were also holding in the 41-to-50 degree range. All refrigeration equipment was working properly. It was suspected that the food items were left out at room temperature during the prep process. Some of the items are transferred from the basement walk-in unit on rolling carts. Those items may have been sitting on the cart for an extended period of time at room temperature. A tall plastic container of grits was cooling in an ice bath. The product was placed into an ice bath approximately 20 minutes earlier and was still approximately 200 degrees. The grits were transferred to a large shallow metal pan for proper cooling. Short ribs prepared two days prior to the inspection were cooled in a deep pan. No temperature violations were confirmed, but this method will not likely ensure proper cooling. Two refillable spray bottles containing cleaning chemicals were not labeled. The bottles were labeled at the time of inspection.

An infographic shows proper temperatures food should be held at to minimize the risk of foodborne illness.
Livingston County Health Department

Great Lakes Family Restaurant

963 S. Grand Ave., Fowlerville

Home-prepared foods were being stored in the walk-in cooler. The items included several 5-gallon buckets of cut tomatoes in a vinegar solution, which were prepared by a family member. The items were removed at the time of inspection. A pie cooler was holding food at 50 degrees. Cream pies and cheesecake were discarded. The pie cooler has been taken out of service and a new unit was ordered. Cream pies are now stored in another unit. A refillable spray bottle containing a chemical degreasing solution did not have a label. Proper chemical labeling was observed upon the inspector’s return.

Jimmy John’s

1504 Lawson Drive, Howell

An employee touched the computer ordering screen while wearing food handling gloves. They returned to prep food without changing the glove. Several employees did not wash their hands before wearing new food handling gloves. Both hand sinks were blocked by equipment. One hand sink was being used to store a water pitcher for the bread-making equipment. The other hand sink contained a sanitizer bottle.  The items were removed at the time of the inspection.

8515 W. Grand River Ave., Brighton

There were multiple employees improperly washing their hands. One employee washed their hands less than the required time and proceeded to use their pants to dry their hands. Another employee washed their hands less than the required time and did not dry their hands. Multiple employees changed soiled gloves but did not wash their hands properly as there were no paper towels to be found at any of the hand sinks in the kitchen. There was shredded lettuce on the line without time stamps. There were no paper towels at either hand sink in the kitchen. An employee was sent to the store during the inspection.

Mimi’s Diner

5589 E. M-36, Pinckney

There was rice in the steam table that had been placed there about an hour and 45 minutes prior. It was at 120 degrees. The steam table should not be used to reheat foods because it takes too long. It was reheated properly to over 165 degrees in the microwave oven and placed back into the steam table. The chlorine sanitizer concentration in the dish machine was too high. It was adjusted. Foods were being improperly cooled in the walk-in cooler. Mashed potatoes and rice were in containers 6-to-8 inches deep with the plastic wrap slightly uncovered on the edge. The rice was already cold, but the potatoes had been placed there an hour and half before and were at 100 degrees. They were moved to uncovered shallow pans. Sausage patties were being cooled in a covered shallow pan and were at 67 degrees. The cover was removed so that the heat was not trapped in. 

Old Hickory Bar

7071 Bennett Lake Road, Fenton

The cooler next to the fryer was holding food at 49 degrees. Deli meat, sliced tomatoes, burger patties and dressing were discarded. Upon the inspector’s return, there were no items in the cooler at time of inspection, but the ambient air read a proper 40 degrees. The in-use knives and utensils were being switched out every shift, which is typically eight hours. The in-use utensils that are in contact with food that is time and temperature controlled for safety need to be washed, rinsed and sanitized at least every four hours. Raw beef was stored in the walk-in cooler above bottled drinks. It was moved away from ready-to-eat food.

MORE: Chiropractic, massage clinic opens on Cleary campus

MORE: Brighton bakery to be featured on Home Shopping Network

Two priority violations were found at:

Jersey Giant Subs

3813 Tractor Drive, Howell

Tomatoes and lettuce had been put out at 11 a.m. and 1 p.m., respectively, but were not marked to indicate the time they were removed from the cooler and the time they must be discarded (4 hours later). They were marked during the inspection. The hand sink in the dish-washing area was blocked by buckets and a cart. They were moved.

Jets Pizza

120 W. Highland Road, Suite 800, Howell

A couple a bottles of cleaner were stored on the prep table near food. They were moved to the chemical storage room. Always store chemicals away from food and clean equipment. There were a couple spray bottles of sanitizer missing labels. They were labeled during the inspection.

Mary’s Fabulous Chicken & Fish

2429 E. Grand River Ave., Howell

A cook came into work, took an order, put food handling gloves on and made the food without washing his hands first. He washes his hands. Several onions in a bin in the walk-in cooler had white mold growth. All of the onions were discarded.

Snappers on the Water

6484 Bennett Lake Road, Fenton

There was a container of moldy food dated from December. It was discarded. There were some cans that were leaky and rusted. They were set aside to be returned.

St. John Catholic Church

2099 Hacker Road, Howell

The two-door cooler in the kitchen is holding food at 60 to 65 degrees. Sour cream, yogurt, milk and sauerkraut with sausage were discarded. There was a large pot of tomato sauce that was improperly cooled in a large container in the cooler. The cooler was broken. The sauce was at the same temperature as everything else (60 to 65 degrees). It was discarded.

Tubby’s Sub Shop

9912 E. Grand River Ave., Ste 500, Brighton

A food handler used gloves that touched raw meat to begin to assemble ready-to-eat sandwich ingredients. She was stopped and told that she must wash her hands and put a new pair of gloves on before touching ready-to eat food. She washed her hands and donned a new pair of gloves. The solution used to wipe down the cutting board contained too much chlorine. Water was added.

One priority violation was found at:

3949 W. Grand River Ave., Howell

A dicer in the cleaned dish area contained food particles. It was cleaned.

Brighton Coffeehouse and Theater

306 W. Main Street, Brighton

The automatic dish machine was calibrated for chlorine sanitizer, but the unit contained quaternary sanitizer. It resulted in sanitizer concentrations that were too weak. The quaternary sanitizer was removed and replaced with proper chlorine sanitizer. Proper sanitizer levels were restored.

Buffalo Wild Wings

9745 Village Place Blvd., Brighton

Foods in a prep cooler were holding 50 degrees in the upper compartment and 45 degrees in the lower compartment. Large metal containers of ranch and blue cheese dressings were holding at 50 degrees. The products were stored on ice, but the amount of ice was not adequate. Ranch and blue cheese dressings, cut tomatoes, cut lettuce, salsa and dairy products were discarded. Upon the inspector’s return, the cooler was repaired and a larger, taller ice bath was being used to hold dressings. 

Community Congregational U.C.C.

125 E. Unadilla Street, Pinckney

The dish machine was out of chlorine sanitizer. The container was tipped to the side to make sure that the machine was pulling the sanitizer, which it was. The bleach will be replaced before the next event.

Emagine Theater

10495 Hartland Square Road, Hartland Township

The dish machine was getting stuck in a cycle where it did not activate the hot water sanitizing cycle. It was repaired.

Hungry Howies

2560 E. Grand River Ave., Howell

An open container of grilled cooked chicken and sausage had a use-by date that had passed. It was discarded.

Jimmy John’s

750 W. Grand River Ave., Brighton

The facility uses both chlorine and quaternary sanitizers. However, only quaternary test strips were available. Chlorine test strips were purchased.

Mt. Brighton Resort

4141 Bauer Road, Brighton

No paper towels were available at the hand sink at Bruin’s Bar. Towels were provided at the time of inspection.

6995 W. Grand River Ave., Brighton

Hot dogs in a reach cooler were kept past their use-by date. They were discarded.

Stout Irish Pub

125 E. Grand River Ave., Brighton

Cooked cabbage, cooked pasta noodles and house-made pizza sauce were expired. The items were discarded.

Sunrise Family Diner

2375 E. Grand River Ave., Howell

A line cook cracked eggs, changed food handling gloves and put a new pair of gloves on before touching ready-to-eat food without washing their hands. 

Sushi Zen

114 W. Grand River Ave., Brighton

A staff member touched dirty dishes while loading them into the dish machine. He began to put clean dishes away without washing his hands.

Wendy’s

1022 S. Michigan Ave., Howell

An employee with painted fingernails was performing food-related tasks such as scooping fries without gloves on. 

Whispering Pines Golf Club

2500 Whispering Pines Drive, Pinckney

The interior of the ice machine had some mold growth. During the golf season it is routinely cleaned, but the club had not been open for a while. 

Wong Express House

9912 E. Grand River Ave., Brighton

A slicer had an accumulation of dried food on the back of the blade. It was taken apart to be cleaned. Grease accumulation was found in between and around equipment.

READ MORE LIVINGSTON COUNTY RESTAURANT INSPECTIONS:

Contact Livingston Daily reporter Jennifer Timar at 517-548-7148 or at jtimar@livingstondaily.com. Follow her on Facebook @Jennifer.Timar99 and Twitter @JenTimar99.

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Death Toll From Indian Capital Communal Violence Rises To 46

person

The death toll during the four-day communal violence in the Indian capital city rose to 46 on Sunday, officials said.

“Today three more bodies were recovered from the violence-hit northeast part of the city,” a police official said. “One of the bodies was found in a canal in Gokalpuri and two were recovered from the Bhagirathi Vihar canal.”

According to the officials, the death toll by now stands at 46. Over 350 people were also injured in the violence that ravaged the city.

Police officials on Sunday said the situation was under control. However, the huge deployment of police and paramilitary remains in the affected parts.

The violence left a trail of damage in the northeastern parts of the city as rioters torched vehicles, vandalised shops and burnt buildings including schools.

A man walks through a vandalized market after violence-ravaged New Delhi, India, Feb. 26, 2020. (Xinhua/Javed Dar)

Many people, especially Muslims, have left their homes in the affected areas and took refuge in the shelters set up by the government.

Delhi Police has come under fierce criticism for its apparent inaction. Locals alleged their calls to police for help proved futile.

The police have set up two Special Investigative Teams (SITs) to probe the violence. According to officials, hundreds of people have been detained in connection with the violence.

The clashes broke out between pro- and anti-Citizenship Amendment Act (CAA) groups in the northeastern part of the city last Sunday and took an ugly turn on Monday and Tuesday.

Protests against the controversial new citizenship law were triggered on Dec. 11 last year, the day India’s upper house of parliament passed the law. Since then there has been no let-up in the protests.

The law aims at granting citizenship to illegal immigrants belonging to six religions – Hinduism, Sikhism, Buddhism, Jainism, Parsi and Christianity – from Bangladesh, Afghanistan and Pakistan. However, it has kept out Muslim immigrants from applying for citizenship.

So far, the violence against the law has killed over 70 people across India.

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Church and State in Montenegro: between National(istic) and Imperial Policies | Political Theology Network

A crisis is brewing in the tiny ex-Yugoslav country of Montenegro. There are massive street protests, attacks on priests, and fights in the Parliament. Various domestic, regional, and international actors, interests and policies are at stake here, giving us the opportunity to learn important lessons about national (and nationalistic) ideological projects, and the role of religion and international (also imperial) aspirations in their creation. And yet, mainstream Western media has shown little interest in the matter. One can speculate why.

The Government of Montenegro proposed new legislation on religious organizations called “The Law on the Freedom of Religion,” which was approved by the Parliament on December 27, 2019.  A draft version of the document is available from the website of the Ministry for Human and Minority Rights, both in the local language and in English. The legislation generated significant controversy due to its treatment of religious organizations, their internal procedures, as well as their property.

Article 4 specifies that:

“Prior to the appointment, i.e. announcement of the appointment if the highest religious leaders, a religious community shall confidentially notify the Government of Montenegro (hereinafter: the Government) about that.”

Article 16, § 1 requires that the application for registration of a religious community shall contain:

“The name of the religious community, which must be different from names of other religious communities and must not contain the official name of other state and its features”

For many, the most problematic article is 52, found under the
section “Transitional and Final Provisions”:

“Religious facilities and land used by the religious communities in the territory of Montenegro and for which is found to have been built or obtained from public resources of the state or have been in state ownership until 1 December 1918, as the cultural heritage of Montenegro, shall be the property of the state. Religious facilities for which if found to have been built on the territory of Montenegro from joint investments of the citizens until 1 December 1918, shall be the property of the state.”

The law caused an outrage among the members of the Orthodox Church
in Montenegro. Let me sketch some of the background which will, hopefully,
render the current crisis more intelligible.

There are four Orthodox dioceses (belonging to the Serbian
Orthodox Church, i.e. Patriarchate of Peć) whose territory is fully or in part
located on the territory of Montenegro. The Orthodox Church (i.e. these four dioceses)
is, by far, the largest religious organization in the country.

The majority of both the clergy and laity view the new legislation as a purposeful targeting of the Church by the Government. They interpret Article 16, § 1 as specifically crafted against the Orthodox Church, as the above-mentioned dioceses in Montenegro belong to the Serbian Orthodox Church. However, the Article 52 appears to be a much more serious threat. Many these churches and monasteries are centuries old, predating even the formation of the modern state of Montenegro. If enacted, Article 52 could lead to the confiscation of Church property and its sacral objects.

Why would the government do this? Why would it go against the Church,
in a country where a significant majority of the population considers itself
Orthodox? This is where things get complicated.

Arguably the chief political authority in Montenegro, over the
past three decades, has been Milo Đukanović. He assumed the office of prime
minister in 1991, and has been in power ever since, performing the roles of
prime minister and president interchangeably (with a couple of years of break,
2006-2008, and 2010-2012). This style of rule brings to mind rulers in other
parts of Europe who have de facto been chief figures in the political
life of their countries for long periods of time, regardless of the name of the
office they would hold in a given moment. Not all long-lasting autocrats are
the same though: There are those who “we” (in the West) do not like very much,
since they refuse to obey us (branded as “evil autocrats”), and there are “our
kind of guys,” who are submissive enough to the Western political and economic
centers (branded as “democratic rulers”). Milo Đukanović, of course, belongs to
the latter group. During his pontificate the country joined the NATO alliance (in
2017), and he has successfully resisted a stronger Russian influence in the
country.

Đukanović, once upon a time, was loyal to Serbian president
Slobodan Milošević, and his allies in Montenegro. However, he switched sides just
in time, and his chief project became an independent Montenegro (proclaimed in
2006) and close cooperation with Western governments, military, and
multinational corporations. This where problems with the Serbian Orthodox
Church in Montenegro begin, in particular with the most prominent figure of
Montenegrin religious life—Metropolitan Amfilohije (Radović). At times partners,
at other times in conflict, this turbulent relationship between the politician
and the metropolitan has ended up, as of now, in an open battle.

Đukanović’s vision of independent Montenegro and the new
Montenegrin identity also includes the vision of an autocephalous (“self-governed”)
“Montenegrin church” which would be loyal (some would suggest obedient as a much better word choice) to the State (i.e., his regime). Amfilohije and
other bishops do not seem to share the same vision. For them, there is no conflict
between an “authentic” Montenegrin identity and Serbian identity, and therefore
no problem with the Orthodox Church in Montenegro being part of the Serbian
Orthodox Church. (Nota bene, many figures and structures within the Serbian
Orthodox Church are by no means innocent in the political games that have been
played in the region, particularly when it comes to Serbian nationalism and the
policies of various autocrats from Belgrade, but that is a topic for another analysis.)

To foster a new Montenegrin identity, Đukanović’s regime started
to promote “Montenegrin Orthodox Church” as an “autocephalous” organization,
headed by the colorful figure of Miraš Dedejić. According to some sources, Dedejić
used to be an admirer of Slobodan Milošević and his policies. He had also been a
priest of the Ecumenical Patriarchate until he was excommunicated by Patriarch
Bartholomew. This organization is not recognized by any of the canonical
Orthodox Churches. Even Đukanović’s support has not been full or unconditional.
One is tempted to say that its purpose has primarily been to put pressure on Amfilohije
to follow the “right path.”  

This is how one can understand the recent actions, at least in one
of their complex and intertwined dimensions: Just as the Ukrainian political
leadership was advancing the (formerly) uncanonical church structures and their
autocephaly in the hope that it would strengthen Ukrainian national identity, as
well as the political elite who championed the project, Montenegrin leadership
might hope that promoting one group, which would be loyal to one political
project and obedient to the political authorities (Amfilohije has not proven
himself in that role), would lead to the recognition of autocephaly of that
group, with same or similar political results. Probably working out of these
hopes, the regime has, then, threatened the confiscation of Church property of
the “disloyal” Church, which is quietly accepted (if not blessed) by the
Western political centers. The trade seems straight-forward, based on a
widely-practiced strategy: “We” (political/economic centers in the West) will
turn a blind eye to violence, undemocratic policies, the autocratic style of
rule, breach of various rights, and so forth, and “you” (local political
elites) will ensure that the (military, economic, political) interests of those
centers are protected and advanced locally.

An obstacle in the case of Montenegro (unlike in the case of
Ukraine) is the fact that the Ecumenical Patriarchate does not seem willing to intervene
to support the formation of a new autocephalous Church, which would advance the
local national identity, being closely connected to the State. Not yet at least,
and not with Miraš’s team as a new autocephalous
church. It seems that there is awareness that right now there are no credible
candidates in Montenegro who would be willing to lead a potential autocephalous
church, neither there is popular support for such project.

For those less familiar with Orthodox ecclesiology, it is worth noting that in Orthodoxy there is no equivalent role to the one of the Roman pontiff. Orthodox ecclesiology has advanced the principle of conciliarity instead of the (universal) primacy of power of one ecclesiastical/imperial center. This does not mean, of course, that there have been no attempts of ecclesiastical seats to assume such power. Indeed, just as the seat of Rome infused the universalist aspirations to power into the emptied shell of the Western (Roman) Empire, so the bishops of “New Rome” (Constantinople) have occasionally aspired to assume both universal ecclesial, and even political authority (at times when the Empire was weakened). This universalism is reflected also in the title of the bishop/patriarch of Constantinople – “Ecumenical” – as the authority of this episcopal seat, as well as the authority of the (Roman) emperor, should ideally stretch over the entire oikoumene (inhabited world). What one can see, based on the recent actions of the Ecumenical Patriarchate, is the (renewed) aspiration to usurp a position within the Orthodox world which would be, in some aspects at least, comparable to the position which the Roman pontiff gradually acquired in the West. This, predictably, provokes a lot of criticism.

The entire episode can thus be understood as yet another example of how the whole concept of autocephaly, the way it is generally understood and practiced in “Orthodox countries” nowadays, is highly problematic. If autocephaly is understood as something “naturally” linked to national/ethnic identities (and/or nation states), it is both theologically unacceptable and very harmful to the body of the Church in long term. Serious Orthodox ecclesiology does not operate with the concept of “national Churches,” although it has been widely (and mistakenly) used both in the public discourse and, sometimes, in academia. Local Churches (i.e. dioceses) are organized as administrative regional ecclesiastical unites, that gather the faithful of a certain territory (for the sake of serving the Liturgy) regardless of their ethnicity, nationality, gender, class, race, etc. The predominant culture or customs have always been embraced in the Orthodox tradition, leaving a trace on how the service is conducted, which language is spoken, etc. However, the identity of the Church is not derived from the ethnic, national or other identities of the majority population of a certain territory, but from the Eucharist as the icon of the Kingdom of God. This is why an autocephalous Church makes sense as a self-governing administrative organization of dioceses of a certain region, having one of the local bishops as their own “head” (having the title of metropolitan, archbishop, pope or patriarch), but not as a “national” institution, or a Church of certain ethnic group (which, following Orthodox ecclesiology, amounts to nothing less than a heresy).

In practice, however, just as local ecclesiastical and political
elites are eager to exploit the (seriously flawed) understanding of autocephaly
as “national institutions,” for the sake of their own power struggles, so is
the Ecumenical Patriarchate. (Neo)imperial policies of ecclesiastical centers
(in this case of Phanar) can thus be very similar to the (neo)imperial policies
of States; both try to manipulate local nationalisms to their own advantage.
Therefore, if they serve the (neo)imperial agendas of “New Rome,” local
nationalisms and local “national” churches will be blessed. If they don’t,
local nationalisms and their cravings for autocephaly will be condemned in the
name of (neo)imperial “universalisms.”

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‘Your seat just ruined my livelihood’: Passenger furious after reclined seat destroys laptop | Stuff.co.nz

person

A passenger aboard a Delta Airlines plane has slammed flyers who recline their seats after his laptop was destroyed by the person in the seat in front of him.

Pat Cassidy, an anchor on Barstool Sports’ ‘Hard Factor News’ podcast, was flying in the US when the incident occurred and took to Twitter from the air to voice his fury.

“@Delta small note for the suggestion box, maybe have a little warning sign or someway to prevent my laptop from being destroyed when the person in front of me reclines their seat,” Cassidy tweeted.

PAT CASSIDY/TWITTER
Pat Cassidy said the passenger in front of him had ‘castrated [his] livelihood’.

“Also, this one is more of a critique than a suggestion. I really appreciate that your flight attendant came over to tell me that the passenger in front of me ‘needs to be able to recline’ and then asked him ‘if he was okay?’ as if your seat hadn’t just ruined my livelihood.”

Infuriated by the incident, Cassidy took to the Barstool Sports website with a piece about his experience, where he referred to the person in the seat in front of him as “the selfish b—tard” who had “castrated [his] livelihood”.

@Delta small note for the suggestion box, maybe have a little warning sign or someway to prevent my laptop from being destroyed when the person in front of me reclines their seat. pic.twitter.com/QHmphXiDhH

— Pat Cassidy (@HardFactorPat)

In the article he explains that he was editing photos on his laptop when the person in seat 13A reclined his seat completely, “destroying” Cassidy’s laptop in the process.

“YOU NEVER FULLY RECLINE. It’s rude and a sign of sociopathy,” Cassidy wrote.

“People that fully recline have no souls.”

The incident reignited the ongoing debate over whether it’s socially acceptable to recline your seat on a plane, with people for and against reclining sharing their views.

Update: @Delta is giving me the equivalent of a $75 gift card and an explanation that you would give a six year old. Cool. pic.twitter.com/etGLUXOOjs

— Pat Cassidy (@HardFactorPat)

Some insisted that Cassidy’s laptop was proof that seats should never be reclined on planes, or at least not fully reclined, while others said that the person in front should have reclined more gently.

However, fellow Twitter users pointed out that it wasn’t entirely 13A’s fault that the laptop had been damaged.

“Am I the only one to think this is not the airline’s fault? You tucked the screen into the tray storage area. Frankly, it’s unsurprising that this would happen,” one replied to Cassidy’s original tweets.

Another chimed in: “Pretty easy to tell if you jam your computer under there that will happen.”

Am I the only one to think this is not the airline’s fault? You _tucked_ the screen into the tray storage area. Frankly, it’s unsurprising that this would happen.

— Hisham (@hisham_hm)

On Saturday, Cassidy updated his Twitter thread with Delta’s response to the incident, saying that the airline had offered him “the equivalent of a $75 gift card and an explanation you would give a six-year-old.”

Attached to the tweet was a screenshot of an email that looks to have come from the Delta customer care team, which explains that personal items damaged in-flight by other passengers aren’t reimbursable.

Instead Cassidy was offered 7,500 bonus miles “as a goodwill gesture” and the airline apologised for any “inconvenience”.

Delta later reached out to Pat, responding to his tweet with: “Afternoon, Pat. I would like to review this further with you. May I give you a call? HDR.”

This article first appeared on Nine Honey and is republished with permission. 

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Mums have their say on the best hospitals to give birth at in the North East – see how yours fared – Chronicle Live

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Two North East hospitals have been voted among the best places in England to give birth as the region once again outperformed the rest of the country in a survey of new mothers.

The annual maternity services poll – which asked 17,151 women about their experiences of pregnancy and birth – found an improvement in the standard of care offered to new mothers on NHS wards nationally.

The poll, from the Care Quality Commission (CQC), showed many women saying positive things about their care during pregnancy and birth, but a poorer experience of care postnatally.

Results published on Tuesday, January 28, showed that a fifth of new mothers were not told how to access help if their mental health were to decline after giving birth and more than one in 10 (12%) were not warned about any changes they might experience to their mental health after having their baby.

Read More

Sunderland Royal Hospital was the best performing nationally with the most positive responses to the survey (88%) when compared to all other trusts and a national average of 78%.

And the Newcastle upon Tyne upon Tyne Hospitals NHS Trust, which runs the Royal Victoria Infirmary, was the only trust to be rated ‘better than expected’ in all three main categories – labour and birth, staff during labour and birth, and care in hospital after the birth.

Gateshead, Northumbria Healthcare (which covers Northumberland and North Tyneside) and County Durham and Darlington trusts scored ‘about the same’ as other trusts overall.

There was no data available for South Tyneside due to the size of the maternity unit.

The poll was among women who gave birth in February 2019.

Sunderland Royal Hospital

High-scoring categories for City Hospitals Sunderland included 9.8/10 of women saying they were treated with respect and dignity during labour and birth and 9.8/10 who said they were spoken to during labour in a way they could understand.

Newcastle’s highest scoring categories for the Royal Victoria Infirmary were also ‘respect and dignity’ (9.8/10) and partners being involved as much as they wanted (9.8/10).

The Northumbria Healthcare NHS Foundation Trust, which runs the Northumbria Specialist Emergency Care Hospital in Cramlington, scored 9.7/10 for partners being as involved as they wanted and for clear communication.

QE Gateshead scored 9.9/10 for partner involvement and 9.3/10 for both skin to skin contact after birth, and the cleanliness of the ward.

County Durham and Darlington were rated ‘better’ than other trusts in the country for confidence and trust in staff (9.5/10) and receiving the information and explanations they needed after the birth (8.6/10).

Read More

Stella Wilson, directorate manager for women’s services, at Newcastle Hospitals, said: “We’re delighted to see such wonderful feedback from the National Maternity Survey.

“Patient feedback is one of the best ways for us to measure the quality of our maternity services and in addition to these fantastic results and through our Maternity Voices Partnership, we actively seek the views of all women across Newcastle who have been in our care.”

Sheila Ford, head of midwifery at South Tyneside and Sunderland NHS Foundation Trust, said: “To be rated nationally as the best performing Trust in the whole country is absolutely fantastic news for the team and shows that local mams are receiving the very best maternity care right here in Sunderland.

“This is testament to the hard work of our maternity team and shows the level of care, dedication and compassion that our staff show to all of the families who choose to deliver with us and I am extremely proud to be part of such a wonderful team.

“There are, of course, areas where we must improve further and we will be looking at the results in detail, alongside other sources of feedback to the Trust, to make sure we continue to listen, learn and continue to develop the very best maternity services for local women in our area.”

Lesley Heelbeck head of midwifery at Gateshead Health said: “In Gateshead we have a really enthusiastic and committed team so it’s good to see such positive ratings from the CQC. Mothers and families are central to developing the services here at Gateshead so we’re always looking at ways we can improve.

“We’ve developed our maternity voices partnerships so that we can talk to local people and listen to their views more closely. Because we’re a smaller unit we aim to provide much more personal and individual care to everyone who comes here to give birth.

“We want as many local people as possible to come here and start their family with us and we aim to improve even further in the future.”

A spokesperson for County Durham and Darlington NHS Foundation Trust, said: “Pregnancy, labour and childbirth are one of the most important experiences women have and we’re delighted to have received this excellent feedback from women in the care of our maternity services.

Northumbria Specialist Emergency Care Hospital, in Cramlington, Northumberland

“In particular, we’re proud that in six categories our score was higher than for most trusts across the country.

“These include the number of women who said they had confidence and trust in those caring for them during labour and birth and the number of women who said their decisions about how they wanted to feed their baby were respected.

“We’re also delighted that we scored above the national average for the number of women reporting that a midwife or health visitor asked them about their mental health.”

Jenna Wall, head of midwifery at Northumbria Healthcare NHS Foundation Trust, said: “Providing our families with the best possible experience while having a baby with us is one of our top priorities and we welcome the feedback from the national maternity survey.

“We are pleased that during labour and birth women felt they were communicated with in a way they could understand, they were treated with respect and dignity and they had confidence and trust in the staff caring for them.

“It is also great that we have scored highly on facilitating skin to skin contact with the baby shortly after birth, involving partners and enabling them to stay as long as they want at our Northumbria hospital.

“These results are testament to our hard-working teams and I’d like to thank them for the dedication and compassion they show to women and their partners at this special time.

“We will, however, continually strive to do even better for our families and further improve the care during and after the birth of a baby.”

See how your trust scored here and how it compared nationally to other trusts:

City Hospitals Sunderland (South Tyneside & Sunderland)

Labour and birth – 9.2/10 – About the same

Staff – 9.3/10 – Better

Care in hospital after the birth – 9.0/10 – Better

County Durham and Darlington NHS Foundation Trust

Labour and birth – 8.9/10 – About the same

Staff – 8.8/10 – About the same

Care in hospital after the birth – 7.6/10 – About the same

Gateshead Health NHS Foundation Trust

Labour and birth – 8.8/10 – About the same

Staff – 8.6/10 – About the same

Care in hospital after the birth – 7.8/10 – About the same

Northumbria Healthcare NHS Foundation Trust

Labour and birth – 8.9/10 – About the same

Staff – 8.8/10 – About the same

Care in hospital after the birth – 7.8/10 – About the same

The Newcastle upon Tyne Hospitals NHS Foundation Trust

Labour and birth – 9.4/10 – Better

Staff – 9.3/10 – Better

Care in hospital after the birth – 8.5/10 – Better

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Rassie to be England’s next head coach?

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IN THE SPOTLIGHT: A photograph snapped in Murrayfield of World Cup-winning Springbok coach Rassie Erasmus has set the England coaching job rumour mill alight.

Erasmus was snapped in the stands and it was posted to Twitter by Telegraph journalist Charlie Morgan.

South Africa play Scotland this July in a two-match series and the argument could be made that the Erasmus was in town on a run of the mill reconnaissance mission. The series kicks off in Cape Town and culminates a week later at Jonsson Kings Park in Durban.

However, Rapport in South Africa are reporting that the coach is in the UK to discuss a possible move to takeover from incumbent England head coach Eddie Jones next year.

Story continues below…

Erasmus has already taken a back seat with the Springboks, with Jacques Nienaber taking over with the Springboks.

Jones’ contract also expires in 2021 and he and the RFU have remained coy about whether or not he will sign beyond that date.

Speaking earlier this month, Jones said: “I heard Pep Guardiola talking about whether he’s going to re-sign at Man City. It’s a bit like that.

“The players tell you whether you should continue or not and that’s what I’m looking it. The players will let me know.

“If the players play well and the team is going well, then maybe you should continue. If the team’s indifferent then maybe they need a change.

“The only reason I’m continuing is because I think this team can improve. Over the next period of time I think we can become the best rugby team ever and that’s the exciting bit.

“The RFU only want me to continue if they think I can improve the team. The contract is important from a legal point of view but they want to win and I want to win.”

It is also reported that there are clauses in Erasmus’ contract which could see him exit South Africa if certain conditions were met.

By Ian Cameron, @RugbyPass

Additional source: Rapport

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Citizen Journalists Who Exposed Beijing’s Lies In Wuhan Have Suddenly Vanished

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Citizen Journalists Who Exposed Beijing’s Lies In Wuhan Have Suddenly Vanished

As we reported late Thursday evening, the death toll from the viral outbreak on mainland China has surpassed 600. With global markets once again in the red, Bloomberg reports that Beijing has silenced two of the citizen journalists responsible for much of the horrifying footage seeping onto western social media.

As BBG’s reporter explains, Chinese citizen journalists Chen Qiushi and Fang Bin have effectively been “the world’s eyes and ears” inside Wuhan (much of the film produced by American news organizations has consisted of drone footage). In recent days, SCMP and other news organizations reporting on the ground and publishing in English have warned that Beijing has stepped up efforts to censor Chinese social media after allowing citizens to vent their frustrations and share news without the usual scrutiny.

On Wednesday, China said its censors would conduct “targeted supervision” on the largest social media platforms including Weibo, Tencent’s WeChat and ByteDance’s Douyin. All in an effort to mask the dystopian nightmare that life in cities like Wuhan has become.

But that brief period of informational amnesty is now over, apparently. Fang posted a dramatic video on Friday showing him being forcibly detained and dragged off to a ‘quarantine’. He was detained over a video showing corpses piled up in a Wuhan hospital. However, he has already been released.

Chen, meanwhile, seems to have vanished without a trace, and is believed to still be in government detention. We shared one of Chen’s more alarming videos documenting the severe medical supply shortages and outnumbered medical personnel fighting a ‘losing battle’ against the outbreak.

The crackdown on these journalists comes amid an outpouring of public anger over the death of a doctor who was wrongly victimized by police after attempting to warn the public about the outbreak. Beijing tried to cover up the death, denying it to the western press before the local hospital confirmed.

The videos supplied by the two citizen journos have circulated most freely on twitter, which is where most in-the-know Chinese go for their latest information about the outbreak. Many “hop” the “great firewall” via a VPN.

“There’s a lot more activity happening on Twitter compared with Weibo and WeChat,” said Maya Wang, senior China researcher at Human Rights Watch. There has been a Chinese community on Jack Dorsey’s short-message platform since before President Xi Jinping rose to power, she added, but the recent crackdown has weakened that social circle.

Chen has now been missing for more than 24 hours, according to several friends in contact with BBG News.

Chen has been out of contact for a prolonged period of time. His friends posted a message on his Twitter account saying he has been unreachable since 7 p.m. local time on Thursday. In a texted interview, Bloomberg News’s last question to Chen was whether he was concerned about his safety as he’s among the few people reporting the situation on the front lines.

It’s all part of the great crackdown that Beijing is enforcing, even as the WHO continues to praise the Communist Party for its ‘transparency’.

“After lifting the lid briefly to give the press and social media some freedom,” said Wang about China’s ruling Communist Party, the regime “is now reinstating its control over social media, fearing it could lead to a wider-spread panic.”

With a little luck, the world might soon learn Chen’s whereabouts. Then again, there’s always the chance that he’s never heard from again.


Tyler Durden

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‘Desexed’ dog gives birth to eight puppies | Stuff.co.nz

dog

This article was first published by RNZ.co.nz and is republished with permission. 

An Auckland couple who picked up a supposedly desexed dog from a Hawke’s Bay pound before Christmas are now caring for eight puppies. 

Sarah Bryant and Hera Nathan are now trying to get answers – and money – from the Hastings District Council, who she claims have offered to put the young pups down. 

Bryant told First Up‘s Lydia Batham that the advertisement on their website stated it would cost $250 for Bella to be desexed, vaccinated, wormed, and get flea treatment.

Bella was picked up the weekend before Christmas last year by Nathan’s sister, who handed over the sum upon arrival but was told Bella was not vaccinated, Bryant said.

“[She] just assumed that was part of the agreement and didn’t ask any questions. She was told she had to sign an adoption form on our behalf, so she did that, and on the form there’s a few boxes and it says vaccinated, wormed, desexed, etc, and there was a cross in the vaccination box, but that was the only one that had any marking in it.”

Bryant said they were confused when they were told by the sister that Bella was not vaccinated, but took her to the vet to get it done.

That was when they decided to ask to check on the other items on the list, including desexing.

“[The vet] looked at [Bella] and said she doesn’t have a scar or anything, it doesn’t appear like she is [desexed], it actually appears like she is on heat. 

“He said he wouldn’t desex her while she is on heat, apparently there’s a potential for that to cause a whole lot of bleeding and issues, so he said to bring her back in March to have her desexed or she could potentially be pregnant, and I’m not going to know for a couple of weeks, so bring her back.”

SUPPLIED/SARAH BRYANT
Bella was adopted the weekend before Christmas by Auckland couple Sarah Bryant and Hera Nathan.

In the meantime, Bryant said they had been trying to contact the pound but got no response. 

When Bella was taken again to be checked, the vet said it could be potentially be a false pregnancy but couldn’t be sure, Bryant said.

“He said the only way you’re going to know, so we can figure out if you can do desexing or not, is to take her in for an ultrasound.”

But while they waited for the day of the booked ultrasound appointment to arrive, Bella delivered eight puppies.

“It was definitely a surprise, and at the time we were just like ‘well it’s happening now’, and just sat with her and waited for all the puppies to come out … and made sure they were healthy.”

Bryant said it was “not what we signed up for”, and had been in touch with the council to possibly ask for money back or pay for Bella’s treatment and something to contribute towards the puppies.

“[The person contacted at the council] said that that wasn’t part of their policy and that their policy would be that we could surrender them and they could put them down, and so I said that’s not an option for us.”

After another chat, the council offered a refund of up to $250 for the desexing, vaccination, worming, flea treatment or again to surrender Bella with the puppies, Bryant said.

She said she was angry about being told they would be put down.

“I tried calling back to say that’s not an acceptable resolution and we need to work this through, and that was on Tuesday and I left a message, and I haven’t heard back again from them.”

SUPPLIED/SARAH BRYANT
Bella and her pups.

In a statement, Hastings District Council said dogs that were adopted were treated for fleas, wormed, vaccinated, microchipped, registered and desexed prior to release at a cost of $250.

However, the council claims that because the owners wanted the dog immediately, it was agreed for them to pay $250 up front but they would have to make their own arrangements for treatment and desexing.

It said the dog was registered and microchipped prior to release, and that the person who picked Bella up was aware none of the treatments, including desexing, were done.

The council said it offered to pay for the treatments up to a cost of $250, but 36 days later, Bella had puppies. 

Since Bella was at such an early stage of gestation when taken, the council said it could not have known she was pregnant.

“We have had discussions with the owner since the birth of the pups – they are wanting us to pay to look after the pups for three months, but this is not council’s responsibility.

“When you adopt a dog, or get a dog from anywhere, you run the risk that it may have health or behavioural issues or, as in this case, be pregnant.”

The council reiterated its offer for the owners to surrender Bella and the puppies, but said they could either foster them until they could be rehomed, or get SPCA’s help with this.

“Unfortunately, in some circumstances euthanasia is the best option.”

Bryant said she was in the process of filling out a Disputes Tribunal form, and would like to see the council apologise.

“I would really like them to change their policy and do what it says on their website they would do.”

Meanwhile, she said the puppies were  the “cutest little things”, and they were getting support from the community.

This article was first published by RNZ.co.nz and is republished with permission. 

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Wrongful Death Suit Against Cabell Sheriff Stays In Mason County | Huntington News

Judge R. Craig Tatterson on June 13 denied a motion to transfer a wrongful death suit against Charles N. “Chuck” Zerkle filed by the estate of Mike Carter from Mason to Cabell Circuit Court.  The ruling came in the form of a letter, and following an April 22 hearing.

The letter gave no detailed explanation for denying the motion. 

According to initial media reports, Carter, 88, died following a collision with Zerkle just before 8 a.m. on Sunday, July 29, 2018 along W. Va. Route 2 in Lesage.  An initial investigation by West Virginia State Police found Carter caused the collision when he failed to obey a stop sign at intersection of Ohio River Rd. and Sanns Dr.

However, the suit filed by Jeffrey W. Carter, administrator of Mike Carter’s estate, places Zerkle at fault.  In his complaint filed Jan. 23, 2019, Carter maintains Zerkle was driving a 2018 GMC Sierra north on Ohio River Rd.“at a high rate of speed in excess of the posted speed limit,” when he struck the elder Carter in a 2002 Ford F-150 pick-up truck while attempting to turn south. 

Additionally, Carter alleges at the time of the collision, Zerkle “was working as an officer, agent and/or employee of …Z&Z Enterprises, Inc. in the course of job related activities.”  Named as a co-defendant in the suit, Z&Z Enterprises in the parent company of  Apple Grove Market, a grocery/convenience store Zerkle owns with his wife, Sandra. 

In the motion filed March 7, Camille E. Shora, with the McLean, Va. law firm of Wilson, Elser, Moskowitz, Eldelman & Dicker, said the suit is in the wrong venue as the accident, and fatality occurred in Cabell, and not Mason, County  Also, though admitting Zerkle is the owner of Z&Z Enterprises, he was not “‘on the clock'” that morning.

In an affidavit attached to the motion, Zerkle avers he “was driving from my home in Cabell county to cut the grass at a property in Mason County.”  The location of the property is not specified.

Since Tatterson’s ruling, the sides have exchanged discovery requests.  Letisha R. Bika with the Charleston law firm of Farmer, Cline and Campbell represents the Carter estate.

No trial date is set. 

Mason Circuit Court, case number 19-C-6

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