Nigeria’s Banks’ Assets To Weaken Due To Pandemic

The Central Bank of Nigeria has introduced intervention schemes to cater for non-interest financial institutions.

The Director, Financial Policy and Regulation Department, Kevin Amugo says the schemes include Non-interest Guidelines for the Accelerated Development Scheme, Intervention in the Textile Sector, Agri-Business, Small and Medium Enterprise Investment Scheme for NIFIs, MSME Development Fund for NIFIs,Non-oil Export Stimulation Facility, Anchor Borrowers’ Programme and Real Sector Support Facility Revised Guidelines.

The CBN,listed the objective to include engaging a minimum of 370,000 youths within the ages of 18 to 35 years in agricultural production nationwide over the next three years in order to reduce youth unemployment.

The intervention scheme breakdown of Financing tenor of six months for grains and broiler production 18 months for cassava; 24 months for egg production and ruminants amongst others.

#BankingSector #CBN #InterestRate #BankAssets #COVID19Pandemic

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Public Transportation Isn’t Always The Best Or The Cheapest Option – Your Mileage May Vary

Sharon and I are big fans of public transportation. For most large cities in the world, it’s one of the cheapest and quickest ways to get from an airport to the city center. Heck, when we were in Frankfurt, we got from our hotel to the subway to the airport in less than twenty minutes. When visiting London, we’ve learned that there are several options other than the “express train” to get from the airport to the city.

The last time we stayed in San Francisco, we were at the Palace Hotel and it was right across the street from a BART station. It was easy to get there from SFO and back to OAK for our departing flight. For this visit, I picked a hotel that was reasonably close to the Powell BART station, figuring that would be the cheapest and best way for us to get into the city. Turns out I was wrong.

When we arrived at the BART station at San Francisco Airport, we had to buy tickets to the city. The fare to the Powell St. Station was $9.65 if we had a Clipper card and $10.15 if we chose to get a paper ticket. The fee for a new Clipper card is $3. Since we were planning on using the BART to get around for most of our trip, we each purchased cards, so our OOP cost was $12.65.

Our flight home was leaving SFO at 9:40 on Sunday morning. One little problem. The BART trains don’t start running until 8AM on Sundays.

Oops!

We ended up having to take a Lyft to the airport. Since I had already registered my Sapphire Reserve with Lyft, we got a 15% discount on our ride with Lyft Pink. I also received 10x Ultimate Rewards, 2x Delta SkyMiles for a ride to the airport and 3x Hilton Honors points for our trip.

I paid $23.63 for our trip to the airport and it only took us 20 minutes to get there.  Our trip to our hotel had taken well over an hour. With Lyft, we were picked up at our hotel and dropped off at our terminal instead of having to walk to the BART station from the hotel and take the AirTrain from the BART station once arriving at SFO.

I paid $25 for our trip into town if you include the price of our Clipper cards. That’s more than I paid for a Lyft.

These calculations will change depending on how many people are in your group. For a solo traveler, the BART will still be a cheaper option, but if you’re a family, a Lyft or Uber will probably be a less expensive and more convenient alternative.

Final Thoughts

When planning trips to and from the airport in a major city, I usually default to look for public transportation. As it turns out, this might not always be the most convenient or cheapest option. Next time, I’ll check to see the price for Uber and Lyft before buying our train tickets.

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Organisers of Exeter’s Black Lives Matter protest have received death threats and abuse – Devon Live

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Death threats and racist abuse against two women who organised a Black Lives Matter event in Exeter have been reported to the police.

More than 400 people gathered at Flowerpot Playing Fields in Exwick on June 7 for the event named Exeter Peaceful Protest Against Racism (George Floyd).

However, organisers Maia Thomas and Sam Draper have endured a wave of abusive messages, some of which threatened their safety.

The most serious threats have been passed to the police, and they have both vowed to continue campaigning.

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Maia told ITV News: [I have had] death threats, messages saying ‘You’re pretty for a black girl, why don’t you use your looks instead of your voice?’

“Messages like, ‘I’m going to throw smoke grenades at you’, saying they are going to attack me. I have to have security in Exeter when I’m at work now.

“So even though this is a good movement, it has put my safety in danger.”

On social media, Maia has received messages which include ‘white supremacy is the way forward’ and ‘white lives matter not blacks, so you need to be dealt with’.

Maia said: “I wouldn’t say I’m scared, but I’m more aware of my surroundings.

“I would rather have to be aware of my surroundings and have my voice heard and have a movement happen than sit back and say nothing.

“If people feel the need to threaten my life just because I want my voice to be heard and to have equal treatment, then I need to do this.”

Alison Hernandez

Mum of one Sam has also been targeted by people questioning why she is choosing to speak up.

She said: “[They say] why are you supporting a black person? And I’m like, ‘why not? She’s my friend’.

“I’m a privileged white woman, I don’t have to go through what Maia and other people have to go through. It shouldn’t be like that.”

Anti-racism

Devon’s police and crime commissioner says she is disgusted by the abuse.

Alison Hernandez told ITV News: “It’s absolutely disgraceful. I want people to stand up for what they believe in, and I will fundamentally support people whatever their view to have the right to say it, and to organise around it.”

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Extraction: Chris Hemsworth reacts as action film nears Netflix record | The Independent

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New Chris Hemsworth film Extraction is about to break a very impressive record.

The Australian actor’s action thriller, produced by directors Anthony and Joe Russo, arrived on Netflix on 24 April, and is on course to be watching by more than 90m households in its first month alone.

Hemsworth announced the news on his instagram page, writing: “Tyler Rake is kicking ass. Extraction is well on its way to becoming the biggest-ever film premiere on Netflix – with an estimated 90m households getting in on the action in the first fours weeks. Thanks to everyone who watched so far!”

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Sharing the full story, not just the headlines

Extraction follows Hemsworth’s mercenary, who is hired to rescue the son of an international crime lord after he is kidnapped.

Despite receiving middling reviews from critics (including a ), audiences are lapping up the film, whose success has no doubt been heightened by the coronavirus lockdown.

Other Netflix titles to benefit from the strict lockdown guidelines include documentary shows and The Last Dance, which is about basketball player Michael Jordan.

However, it’s important to note that the service picks and chooses which titles it releases stats for, with a view to highlighting its successes – and that it has recently changed how it registers views.

While the service used to count a view when a user streamed at least 70 per cent of a title, it now registers them when any account has watched at least two minutes of a film or TV show.

Netflix’s belief is that if someone watches two minutes of something, they have made an intentional choice to keep it on. Autoplay is not taken into account.

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Tony Allen: the Afrobeat pioneer’s 10 finest recordings | Music | The Guardian

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Listen to a playlist of Ammar’s selections:

Fela Kuti: Roforofo Fight (Roforofo Fight, 1972)




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Roforofo Fight is the earliest cohesive expression of Tony Allen and saxophonist Fela Kuti’s Afrobeat sound: part Yoruba polyrhythm, part Nigerian highlife melody, part calypso swing, and all shuffling swagger. Allen and Kuti had been playing together for the best part of eight years at this point, mixing highlife and jazz, but a 1969 trip to the US proved pivotal, exposing Kuti to the radicalism of the Black Panther movement and leading to the formulation of his militant aesthetic Africa ‘70 band. On the title track of Kuti’s second album to be recorded after the trip, Allen takes centre stage with his undulating groove, slapping the snare on the jaunty offbeats to counter Kuti’s forceful diction. An enticing taste of things to come.

Fela Kuti: Water No Get Enemy (Expensive Shit, 1975)




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Afrobeat rhythms seem deceptively simple: a steadily paced, off-kilter shuffle that holds the beat without succumbing to the western convention of landing the snare on the third beat of the bar. Try to play an Allen line, though, and you soon realise how much ghosting and embellishment is going on below the surface – doubles splayed on the first note of a phrase, kick drums scattered throughout. And yet, the groove remains even when it feels like it might fall apart. Water No Get Enemy is the perfect example: a hip-swaying mid-tempo horn line sits atop Allen’s liquid shuffle while Kuti uses the amorphous imagery of water to outline methods of resistance to Nigeria’s reactionary government.

Fela Kuti: Zombie (Zombie, 1976)




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By the mid 70s, Kuti’s politics of resistance was reaching its peak. Zombie was its most forceful expression, Kuti’s lyrics characterising the violent Nigerian army as mindless zombies. You can feel the force of his frustration through his blistering saxophone as it meanders over the highlife guitar line, while Allen’s snappy, shaker-heavy rhythm is the ever-reliable foundation for Kuti’s social message. The song’s success in Nigeria was not without consequences, leading to a severe beating for Kuti, the torching of his studio and his elderly mother being thrown from a window and killed.

Tony Allen: Nepa (Never Expect Power Always, 1984)

Kuti had a domineering relationship to his bandmates, demanding all recording royalties for himself despite Allen’s role as musical director. As the 70s wore on and the group’s popularity increased, so did the dissent in its ranks. By 1979, Allen had recorded three albums as bandleader and so decided to leave the ‘Africa 70, taking many of its members with him. The greatest recording of his new era is 1984’s Nepa – an attack on the notoriously unreliable Nigerian Electrical Power Authority. Here Allen continues Kuti’s lineage of playful socio-political criticism, this time updating the Afrobeat sound to include dub-inflected electronics and fusion funk. It would become representative of Allen’s all-encompassing musical appetite in the years to come.

The Good, the Bad & the Queen: The Good, the Bad & the Queen (The Good, the Bad & the Queen, 2007)

As the 90s continued and Allen was establishing himself as an architect of Afrobeat in his own right, especially in the wake of Kuti’s 1997 death, his own genre-eating journey was evolving further into electronics and collaboration. A longtime fan of the genre, Damon Albarn enlisted Allen for his supergroup, The Good, the Bad & the Queen, featuring the Clash’s Paul Simonon on bass and the Verve’s Simon Tong on guitar. The sprawling title track is the closest we see Allen to cutting loose behind the kit and producing an unabashed rock sound behind Tong’s voluminous closing solo – a testament to his energetic versatility.

Moritz von Oswald: Sounding Line 1 (Sounding Lines, 2015)




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Perhaps the strangest and least well-known of Allen’s collaborations is that with the techno producer Moritz von Oswald, who replaced his longtime drummer Vladislav Delay with Allen for his 2015 album Sounding Lines. Allen produces a truly remarkable sound: a warped and manipulated series of electronics. The opening track sees Allen superimpose an Afrobeat shuffle on to a wobbly dub that builds over 10 minutes to create a simmering, electro dancefloor odyssey.

Tony Allen: A Night in Tunisia (A Tribute to Art Blakey and the Messengers, 2017)




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Allen’s first love was always jazz and he referenced throughout his life the work of rhythmic mastermind Max Roach and explosive powerhouse Art Blakey as major influences. This 2017 Blue Note recording was a welcome opportunity for Allen to finally delve into those roots and lay down his own interpretations. Across its four tracks Allen tackles some of Blakey’s best-loved tunes, like a straight-eighths Moanin’, but his Afrobeat-inflected Night in Tunisia is a work of genius, transforming the horn line into a punchy, driving vamp.

Tony Allen: Wolf Eats Wolf (The Source, 2017)




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Continuing his jazz explorations, Allen delivered his first album of original compositions as a bandleader for legendary jazz label Blue Note. The culmination of his decades of musical exploration, it interweaves metallic electronics with warm percussion, bright horn lines and that ever-present drum language. On Wolf Eats Wolf, Allen is comfortably experimental, putting a Synclavier to work over a highlife guitar line and Kuti-referencing horns to create an eminently danceable new jazz standard.

Tony Allen and Jeff Mills: Locked and Loaded (Tomorrow Comes the Harvest, 2018)




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Never one to be pigeonholed, on 2018’s Tomorrow Comes the Harvest Allen paired up with techno wizard Jeff Mills to further the electronic experiments he had begun with Von Oswald. Largely formulated for modular live performances, the record has a wonderfully loose, improvisatory feel. It hits its stride on the propulsive Locked and Loaded as Allen’s shuffle dissipates into white noise beneath Mills’s distorting sub bass. Even in the grid-work of Mills’ techno, Allen manages to swing.

Tony Allen and Hugh Masekela: Never (Lagos Never Gonna Be The Same) (Rejoice, 2020)




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In 2010, Allen paired up with trumpeter Hugh Masekela, a longtime collaborator and giant of South African jazz. Rejoice was released a decade later, following Masekela’s death in 2018, and now stands as Allen’s last released recording. As its title indicates, the album is a sun-dappled, joyous listening experience celebrating both artists’ effortless ability to make us shake a leg. Never (Lagos Never Gonna Be The Same) plays as an homage to Kuti and it serves as a perfect reminder that although our musical greats ultimately pass on, their legacy lies in each note, ready and willing to be dusted off, played and reinterpreted all over again.

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Death toll from coronavirus in care homes set to be published daily | London Evening Standard

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The death tolls for the number of people who have died in care homes after testing positive for coronavirus will now be announced daily, Matt Hancock has said.

The Government previously faced criticism over the fact the daily death toll figures provided by the Department of Health only include hospital fatalities.

To date, figures for deaths in care homes and in the community have been released weekly by the Office for National Statistics.

The news comes as the Care Quality Commission revealed today that 4,343 Covid-19  deaths occurred in care homes between April 10 to the 24.​

Speaking in Downing Street, Mr Hancock said: “From tomorrow we’ll be publishing not just the number of deaths in hospital each day but the number of deaths in care homes and the community too.”

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The Health Secretary said that this was part of a Government effort to “bring as much transparency as possible” during the Covid-19 pandemic.

He added: “This will supplement the ONS and CQC weekly publication and all add to our understanding of how this virus is spreading day by day.”

The move will also “help inform the judgments that we make as we work to keep people safe,” Mr Hancock said.

Answering questions from journalists during the press briefing, he said the spread of Covid-19 through care homes is “absolutely a priority” for the Government.

The Health Secretary also revealed that after successful pilots, the government will be rolling out coronavirus testing to asymptomatic residents and staff in care homes in England as well as staff and patients in the NHS.

“This will mean that anyone who is working or living in a care home will be able to get access to a test whether they have symptoms or not,” he stated.

“I am determined to do everything I can to protect the most vulnerable.”

Professor John Newton, co-ordinator of the national testing effort, addressing the spread of the virus in care homes, said: “We’ve done some intensive studies of infection in care homes.

“What that showed was that the presence of symptoms was not really a good marker in the care home setting, both among residents and staff, for the presence of the virus.

“There were significant numbers who were asymptomatic who had the virus and so we have massively increased the amount of testing available.

Listen to The Leader: Coronavirus Daily podcast

“We have now tested 25,000 residents in care homes and we are rolling out testing now to symptomatic and asymptomatic residents, as well as providing testing through the drive-thru centres and other means.”

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Coronavirus live updates: U.S. death toll nears 55,000

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The U.S. coronavirus death toll neared 55,000 early Monday, with more than 972,000 confirmed cases, according to NBC News’ tally.

The grim milestone comes as the White House coronavirus task force coordinator Dr. Deborah Birx warned that many of the social distancing measures that have upended American life will be a fixture through the summer.

To get a more accurate picture of the virus’ spread, the U.S. needs a “breakthrough” on coronavirus testing, she said on NBC News’ “Meet the Press” Sunday.

Meanwhile in Italy, Europe’s hardest hit country, the prime minister laid out plans for a phased end to restrictions, including the opening of restaurants and libraries in mid-May.

Download the NBC News app for latest updates on the coronavirus outbreak.

45m ago / 12:13 PM UTC

British Grand Prix could take place behind closed doors, French race cancelled

The British Grand Prix and French Grand Prix are the latest global sporting events to be affected by coronavirus.

France has called off its event altogether, while Britain’s race might take place without fans this year as the U.K. government continues to ban large gatherings to prevent the spread of coronavirus.

Silverstone, the track that has hosted the race since 1952, said it was discussing with the government a plan to show the event on TV for free instead. Silverstone said it would give health care workers tickets for the 2021 event.

✍️An update from our Managing Director, Stuart Pringle about the Formula 1 Pirelli British Grand Prix 2020. pic.twitter.com/APIXq8F2OS

— Silverstone (@SilverstoneUK)

Nursing home industry pushes for immunity from lawsuits during coronavirus emergency

As the COVID-19 death toll at nursing homes climbs to nearly 12,000, the nursing home industry is pushing states to provide immunity from lawsuits to the owners and employees of the nation’s 15,600 nursing homes.

So far at least six states have provided explicit immunity from coronavirus lawsuits for nursing homes, and six more have granted some form of immunity to health care providers, which legal experts say could likely be interpreted to include nursing homes.

Patient advocates worry that nursing homes accused of extreme neglect could avoid liability.

“I can’t even believe this is a topic of discussion,” said Anny Figueroa, whose 55-year-old mother was a resident at Andover Subacute & Rehab Center in New Jersey, where law enforcement discovered 17 bodies in a makeshift morgue this month.

1h ago / 11:52 AM UTC

Italian expat in Sweden shows off country’s lack of restrictions

An Italian PhD candidate living in Sweden has documented the “parallel universe” of daily life in Sweden, a country where the government has not enforced strict social distancing measures amid Covid-19.

Alessandra Palusco, 28, who is studying at the University of Orebro, posted several videos on social media showing life in Sweden and the difference with countries living under lockdown. Palusco told NBC News via text message that she lied to her family back in Italy to reassure them that locals are wearing masks in public,”otherwise they would go crazy.”

Sweden’s Foreign Minister Anne Linde denied in a news conference on April 17 that “life goes on as normal in Sweden,” but Palusco believes that the Swedish government has not taken firm enough action on the virus. “I really don’t understand, if they implement certain measures, it means that they basically know that the situation is dangerous,” Palusco told NBC News.

“Masks do very little, if anything at all”. We wont forget the way you misinformed people, and this is the result 👏👏👏 @Folkhalsomynd #COVID19 #COVID19sverige #covid19swed pic.twitter.com/BaUEDro1J4

— Alessandra • 桑德拉 (@alex_paiusco)

1h ago / 11:37 AM UTC

Salons, florists and garden centers allowed to reopen in Switzerland

Hospitals in Switzerland reopened for outpatient and non-urgent procedures on Monday as the country began easing measures put in place to contain the coronavirus outbreak. 

Beauty salons, DIY stores, garden centers and florists were also permitted to reopen, the government announced as it laid out its staged plans to lift the lockdown. On May 11th, elementary schools and other shops will be allowed to reopen “if the situation allows,” the government said in a statement. Then in June, high schools, zoos and libraries will be allowed to open their doors.

Switzerland has nearly 30,000 confirmed cases of COVID-19 and 1,600 deaths since the pandemic began.

2h ago / 11:19 AM UTC

Two funeral home workers in Harlem, N.Y. said they are turning away families whose loved ones have died because there are more bodies than they can handle.

“We want to be able to help everyone,” manager Alisha Narvaez told “Kasie DC” Sunday evening, adding that they often have to tell families to call back because they have no room. Both women, who work at International Funeral and Cremation Services, said the emotional toll of helping the families weighs heavily on them.

“Just today I had a family call because they’re pretty much at the cut-off time for the hospital to hold their loved one. And out of desperation, she cried to us and she begged,” said funeral director Nicole Warring, adding the woman was fearful her father would end up buried in an unmarked grave. “It’s tough when we just don’t have the capacity.”

Iran to open mosques in areas with few coronavirus cases

Iran plans to loosen restrictions in some parts of the country by classifying regions as either white, yellow or red based on the spread of the coronavirus, President Hassan Rouhani has said.

Iran has been one of the Middle East’s worst hit countries with more than 91,000 cases of coronavirus recorded as of Monday, as well as around 5,800 deaths.

2h ago / 10:37 AM UTC

Nearly 2 million people download Australia tracking app

More than 1.8 million people downloaded a new tracking app released by the Australian Government that claims to “speed up contacting people exposed to coronavirus,” according to the country’s Health Department.

COVIDSafe is available to all Australian residents, though participation is not mandatory. It tracks the movement and interaction of residents with the aim of quickly locating and informing anyone that may have been in contact with someone who has tested positive for COVID-19. If a user tests positive, the other users of the app that have been in close proximity to that initial user will be informed so they can get tested and isolate themselves. Health officials will not name the person who was infected.

Officials have said 40 percent of the population will need to download the app for it to work effectively. Australia has been one of the most successful countries in fighting the coronavirus pandemic, recording just 83 deaths and 6,700 cases.

3h ago / 9:53 AM UTC

Italy’s prime minister lays out plan to slowly reopen in May

Construction workers and factories will restart in Italy on May 4, Prime Minister Giuseppe Conte said as he laid out plans for a phased end to the country’s strict nationwide lockdown. 

Public parks will reopen then as will restaurant takeout and delivery services. “We will live with the virus and we will have to adopt every precaution possible,” Conte said Sunday evening. Shops, museums, exhibitions and public libraries will reopen on May 18, and hairdressers, bars and restaurants will be open from June 1. Schools however, will remain closed until September.

The announcement comes a week after the country reported its first decline in the number of people sick with coronavirus since the virus hit. The country has recorded 26,384 coronavirus deaths and 195,351 confirmed cases.

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UK’s coronavirus death toll rises by 684 to 3,605 in biggest jump yet – Mirror Online

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The UK’s coronavirus death toll has soared to 3,605 after 684 patients died in just 24 hours – the biggest single day increase yet.

The figure does not include people who have died at home. The previous total stood at 2,921 deaths.

The number of confirmed cases has increased to 38,168 after 4,450 more people tested positive.

Most of the deaths have been in England (3,244), followed by Scotland (172), Wales (141) and Northern Ireland (48).

Two NHS nurses, who were both mothers in their 30s with three young children, are among the latest patients to die after battling Covid-19 in hospital.

The grim news came as Health Secretary Matt Hancock, who is back at work after battling the virus, said the Government expects the virus to peak in Britain in the next few weeks and Prime Minister Boris Johnson, who is still infected with Covid-19 and isolating, urged people to stick with social distancing in a bid to flatten the curve.

Have you been affected by coronavirus? Email webnews@mirror.co.uk.

Aimee O'Rourke

The Department of Health said: “As of 9am on 3 April 2020, 173,784 people have been tested, of which 38,168 were confirmed positive.

“As of 5pm on 2 April 2020, of those hospitalised in the UK who tested positive for coronavirus, 3,605 have died.”

Public Health England said 11,764 tests were carried out on Thursday in England, while testing capacity for inpatient care in the country currently stands at 12,799 tests per day.

Two NHS nurses were among the latest patients to die.

BBC Radio 4

Mum-of-three Areema Nasreen, 36, was in intensive care on a ventilator after testing positive for the virus.

She worked at Walsall Manor Hospital in the West Midlands.

In Kent, Aimee O’Rourke, 38, died at the Queen Elizabeth The Queen Mother Hospital in Margate, where she worked.

The mum-of-three was hailed as a “brave angel” as her family said in a tribute: “Aimee was a beautiful woman and a valued NHS nurse.”

Boris Johnson

More than 10,000 tests carried out

Friday’s figures from the Department of Health show that for the second day running more than 10,000 new people were tested in the UK for coronavirus.

A total of 10,590 new people were reported as being tested in the 24 hours to 9am April 3.

The equivalent figure for April 2 was 10,215.

The total number of people in the UK tested since the outbreak began is now 173,784.

This is the equivalent of around 261 people in every 100,000, or 0.3% of the population.

The number of coronavirus-related hospital deaths reported by the Department of Health stood at 3,605 as of 5pm April 2.

It took 19 days for this number to pass 300. It has taken further 11 days to pass 3,000.

Meanwhile, the number of confirmed cases of coronavirus in the UK has taken two weeks to go from just under 4,000 (3,983 as of 9am March 20) to just under 40,000 (38,168 as of 9am April 3).

Commenting on the death of Ms Nasreen, Mr Hancock said: “I pay tribute to the NHS staff who’ve died serving the NHS, serving the nation.

“It shows the incredible bravery of every member of the NHS who goes into work knowing that these dangers are there.

“I think it is a testament to every doctor and nurse and paramedic and other health professional who is working in the NHS in these difficult times.

“And I think the whole nation is grateful.”

About 35,000 front-line NHS staff are not currently in work due to coronavirus, said Mr Hancock.

He said testing figures for health staff “should” rise to thousands a day in the next few weeks.

The Government has set a goal of testing 100,000 people a day across the whole of the UK by the end of April following widespread criticism of its testing strategy.

The Prime Minister’s spokesman said the 5,000-plus NHS staff who had been tested had mainly been tested at new testing sites.

Health Secretary

A total of 172 patients have died in Scotland after testing positive for coronavirus, up by 46 from 126 on Thursday.

3,001 people have now tested positive for the virus in Scotland, up from 2,602 the day before.

Officials said 176 people are in intensive care with coronavirus or coronavirus symptoms, and increase of 14 on Thursday.

First Minister Nicola Sturgeon warned: “I want to be very clear that nothing I have seen gives me any basis whatsoever for predicting the virus will peak as early as a week’s time here in Scotland.”

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A total of 24 patients have died after testing positive for coronavirus in Wales, bringing the total number of deaths in the country to 141, health officials said.

Public Health Wales said 345 new cases had tested positive for Covid-19, bringing the total number of confirmed cases in Wales to 2,466.

Dr Robin Howe, from Public Health Wales, said “345 new cases have tested positive for Covid-19 in Wales, bringing the total number of confirmed cases to 2,466, although the true number of cases is likely to be higher”.

Dr Howe added: “Twenty-four further deaths have been reported to us of people who had tested positive for Covid-19, taking the number of deaths in Wales to 141.

Louisa Jordan

“We offer our condolences to families and friends affected, and we ask those reporting on the situation to respect patient confidentiality.”

The Welsh Government will introduce a law compelling all employers to make sure their workers keep two metres apart, Wales’ First Minister has said.

Mark Drakeford said the social distancing legislation, the first in the UK, would require bosses to “put the needs of their workforce first” when it comes into force on Monday or Tuesday of next week.

The number of people who have died in Northern Ireland after contracting coronavirus has risen by 12 to 48, health officials said.

Testing has resulted in 130 new positive cases, bringing the total number of confirmed cases in the region to 904.

Manchester's Central Complex

In England, two siblings of Ismail Mohamed Abdulwahab, the 13-year-old London boy who died after testing positive for coronavirus, have also developed symptoms, according to a family friend who launched an online appeal.

The development means Ismail’s mother and six siblings are forced to self-isolate and cannot attend his funeral in Brixton on Friday, Mark Stephenson said.

Meanwhile, Prince Charles, who tested positive for coronavirus last month, officially opened the NHS Nightingale Hospital at the ExCeL centre in east London.

The Prince of Wales, 71, appeared via video-link from his Scottish home of Birkhall and spoke to those gathered at the entrance of the new temporary hospital.

He said: “It is without doubt a spectacular and almost unbelievable feat of work in every sense, from its speed of construction – in just nine days as we’ve heard – to its size and the skills of those who have created it.

Mark Stephenson

NHS Nightingale Hospital – the facts

The NHS Nightingale Hospital has been built in east London in the ExCel convention centre.

The facility will be used to treat Covid-19 patients transferred from intensive care units across London

Just one ward will need 200 members of staff

“An example, if ever one was needed, of how the impossible could be made possible and how we can achieve the unthinkable through human will and ingenuity.”

Charles added: “The creation of this hospital is above all the result of an extraordinary collaboration and partnership between NHS managers, the military and all those involved to create a centre on a scale that has never been seen before in the United Kingdom.

“To convert one of the largest national conference centres into a field hospital, starting with 500 beds with a potential of 4,000, is quite frankly incredible.”

The prince and Mr Hancock both recently ended self-isolation after contracting the virus and Charles commented on the fact they had recovered.

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He said: “Now I was one of the lucky ones to have Covid-19 relatively mildly and if I may say so I’m so glad to see the Secretary of State has also recovered, but for some it will be a much harder journey.”

Shortly after he spoke, Buckingham Palace confirmed the Queen has recorded a special broadcast on the coronavirus outbreak to be broadcast on Sunday night.

Previously, it was said that the 93-year-old monarch, who is isolating with Prince Philip, 98, at Windsor Castle, was preparing to make a televised address to calm the nation’s nerves, but was waiting for the “right moment” to address the country.

Mr Hancock, meanwhile, praised all those involved in the setting up of the hospital, adding the “extraordinary project”, the core of which was completed in just nine days, was a “testament to the work and the brilliance of the many people involved”.

Matt Hancock

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He also praised the NHS and the way its staff are dealing with the virus crisis.

The Health Secretary said: “In these troubled times with this invisible killer stalking the whole world, the fact that in this country we have the NHS is even more valuable than before.”

Asked about the number of ventilators currently in use and how many are expected to arrive next week, Mr Hancock said: “We’ve obviously got a big programme to ramp up the number of ventilators and we now have more ventilators than we had before.

“And we’re going to need them for this hospital and I’m just going to go and have a look at that now.”

Pressed for exact numbers, Mr Hancock did not respond.

Northern Ireland

Speaking on BBC Radio 4’s Today programme earlier, Mr Hancock said it is unclear whether he is now immune to Covid-19.

He described having coronavirus as a “pretty unpleasant experience” with an “incredibly” sore throat and a feeling of “having glass in my throat”.

He said he has lost half a stone in weight.

Prime Minister Boris Johnson remained in isolation in Downing Street after testing positive for the virus.

He was “feeling better” but still had a fever on Friday.

nurse and paramedic

In a video on social media, the Prime Minister urged the public to stick with social distancing and not be tempted to “hang out” in the warmer weather predicted for this weekend.

“In my own case, although I’m feeling better and I’ve done my seven days of isolation, alas I still have one of the symptoms, a minor symptom, I still still have a temperature,” he said.

“So, in accordance with government advice I must continue my self-isolation until that symptom itself goes.”

Mr Johnson said people must not be tempted to break social distancing rules as the weather warms up even if they were going “a bit stir crazy”

In England, more than 26.7 million units of personal protection equipment (PPE) were delivered to 281 NHS “trusts and providers” on Thursday, Downing Street confirmed.

Prime Minister

Mr Johnson’s spokesman said: “That included 7.8 million aprons, 1.7 million masks and 12.4 million gloves.”

It follows the new guidance issued by Public Health England about the level of protection health staff should wear depending on the patient situation.

There would be no new guidance published on the public wearing masks or face coverings when out of the house, said the spokesman.

The spokesman said “surveillance” of the population to determine the spread of coronavirus was ongoing, with 3,500 antibody tests carried out per week.

“This is a population surveillance programme which we have been carrying out since February,” said the spokesman.

“It is being done by Public Health England at their campus which is at Porton Down.

“We currently have capacity for 3,500 of these surveillance tests to be carried out this week which is enough for small-scale population sampling.”

Two newly-planned temporary hospital sites have been agreed at the University of the West of England and the Harrogate Convention Centre.

They will join other sites due to open at Birmingham’s National Exhibition Centre and Manchester’s Central Complex.

Construction of a temporary hospital called the NHS Louisa Jordan is underway in Glasgow.

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

person

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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Coronavirus claims another major tech event: Kaspersky’s Security Analyst Summit postponed | ZDNet

Coronavirus: How hackers are exploiting the epidemic to steal your information
Karen Roby interviewed a cybersecurity expert about a different threat than COVID-19 brings.
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Kaspersky’s Security Analyst Summit (SAS) has been postponed due to fears surrounding the novel coronavirus outbreak. 

SAS2020 was due to open in 32 days, with attendees hitting the streets of Barcelona from April 6 – 9. The conference caters to thousands of security professionals, researchers, and members of both government agencies and law enforcement. There are talks revolving around new research and cybersecurity trends, cybersecurity roundtable discussions, and workshops.

Several weeks ago, ZDNet asked Kaspersky if there were any plans to cancel or postpone the summit due to the cancellation of GSMA’s Mobile World Congress (MWC) — also intended to take place in Barcelona — due to novel coronavirus concerns.

At the time, the cybersecurity firm said there were “no plans” to cancel SAS, but Kaspersky was “closely monitoring the situation.”

Now, it seems the decision has been made to postpone — not cancel — SAS for the “health and safety of all stakeholders.”

The reason given for the postponement resonates as a past attendee of SAS for some years. 

“We realized it won’t be “a real SAS” if we can’t share hugs, handshakes and beer glasses,” the company says. “We will do it properly when the time is right and everyone feels safe and comfortable.”

Kaspersky intends to go ahead with SAS during the September – November timeframe, but the cybersecurity firm has yet to decide on actual dates or places. For now, the SAS website has a placeholder date of September 1-1, Barcelona. 

Refund requests will be honored but Kaspersky added on a Twitter thread announcing the decision that “we would prefer if you keep your ticket and use it later this year :).”

Kaspersky’s Security Analyst Summit is the latest tech event to be impacted by the novel coronavirus outbreak. 

Also known as COVID-19, the respiratory illness has been confirmed in over 92,000 cases at the time of writing, claiming the lives of 3,200 people. The World Health Organization (WHO) recently said that the fatality rate of COVID-19 is 3.4%, higher than the seasonal flu, but is an illness that is not as easily transmitted. 

As travel bans surface, companies restrict international air travel, and large, public gatherings are scrapped on the side of caution, events are being canceled, postponed, or switched over to virtual, remote options instead. 

ZDNet’s Bill Detwiler has compiled a list of all the technology events facing disruption or cancellation due to COVD-19, which can be accessed here. Prominent events include Adobe Summit, Facebook F8, Microsoft MVP Global Summit, Nvidia GTC, and TNW. 

On Tuesday, Google I/O, the tech giant’s annual developer conference, was canceled. The event, due to take place at Shoreline Amphitheatre in Mountain View, California, will be replaced with a virtual option. Ticket holders will be refunded. 

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