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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anna Bertone:   Exactly.

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

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

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

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

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

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

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

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

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

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

They only had an 11% cesarean rate then?

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

…And what about for the babies then? – 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anna Bertone:   Correct. Yes.

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

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

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

Anna Bertone:   That’s my understanding. Correct.

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

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

So it’s quite a global sample.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anna Bertone:   Yes. More worried.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Article 4 specifies that:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


Tyler Durden

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Facebook keeps policy protecting political ads | ABS-CBN News

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Facebook logos are seen on a screen in this picture illustration taken Dec. 2, 2019. Johanna Geron, Reuters/file

SAN FRANCISCO — Defying pressure from Congress, Facebook said on Thursday that it would continue to allow political campaigns to use the site to target advertisements to particular slices of the electorate and that it would not police the truthfulness of the messages sent out.

The stance put Facebook, the most important digital platform for political ads, at odds with some of the other large tech companies, which have begun to put new limits on political ads.

Facebook’s decision, telegraphed in recent months by executives, is likely to harden criticism of the company heading into this year’s presidential election.

Political advertising cuts to the heart of Facebook’s outsize role in society, and the company has found itself squeezed between liberal critics, who want it to do a better job of policing its various social media platforms, and conservatives, who say their views are being unfairly muzzled.

The issue has raised important questions regarding how heavy a hand technology companies like Facebook — which also owns Instagram and the messaging app WhatsApp — and Google should exert when deciding what types of political content they will and will not permit.

By maintaining a status quo, Facebook executives are essentially saying they are doing the best they can without government guidance and see little benefit to the company or the public in changing.

In a blog post, a company official echoed Facebook’s earlier calls for lawmakers to set firm rules.

“In the absence of regulation, Facebook and other companies are left to design their own policies,” Rob Leathern, Facebook’s director of product management overseeing the advertising integrity division, said in the post. “We have based ours on the principle that people should be able to hear from those who wish to lead them, warts and all, and that what they say should be scrutinized and debated in public.”

Other social media companies have decided otherwise, and some had hoped Facebook would quietly follow their lead. In late October, Twitter’s chief executive, Jack Dorsey, banned all political advertising from his network, citing the challenges that novel digital systems present to civic discourse. Google quickly followed suit with limits on political ads across some of its properties, though narrower in scope.

Reaction to Facebook’s policy broke down largely along party lines.

The Trump campaign, which has been highly critical of any attempts by technology companies to regulate political advertising and has already spent more than $27 million on the platform, largely supported Facebook’s decision not to interfere in targeting ads or to set fact-checking standards.

“Our ads are always accurate so it’s good that Facebook won’t limit political messages because it encourages more Americans to be involved in the process,” said Tim Murtaugh, a spokesman for the Trump campaign. “This is much better than the approaches from Twitter and Google, which will lead to voter suppression.”

Democratic presidential candidates and outside groups decried the decision.

“Facebook is paying for its own glowing fake news coverage, so it’s not surprising they’re standing their ground on letting political figures lie to you,” Sen. Elizabeth Warren said on Twitter.

Warren, who has been among the most critical of Facebook and regularly calls for major tech companies to be broken up, reiterated her stance that the social media company should face tougher policies.

The Biden campaign was similarly critical. The campaign has confronted Facebook over an ad run by President Donald Trump’s campaign that attacked Joe Biden’s record on Ukraine.

“Donald Trump’s campaign can (and will) still lie in political ads,” Bill Russo, the deputy communications director for Biden, said in a statement. “Facebook can (and will) still profit off it. Today’s announcement is more window dressing around their decision to allow paid misinformation.”

But many Democratic groups willing to criticize Facebook had to walk a fine line; they have pushed for more regulation when it comes to fact-checking political ads, but they have been adamantly opposed to any changes to the ad-targeting features.

On Thursday, some Democratic outside groups welcomed Facebook’s decision not to limit micro-targeting, but still thought the policy fell short.

“These changes read to us mostly as a cover for not making the change that is most vital: ensuring politicians are not allowed to use Facebook as a tool to lie to and manipulate voters,” said Madeline Kriger, who oversees digital ad buying at Priorities USA, a Democratic super PAC.

Other groups, however, said Facebook had been more thoughtful about political ads than its industry peers.

“Facebook opted against limiting ad targeting, because doing so would have unnecessarily restricted a valuable tool that campaigns of all sizes rely on for fundraising, registering voters, building crowds and organizing volunteers,” said Tara McGowan, chief executive of Acronym, a non-profit group that works on voter organization and progressive causes.

Facebook has played down the business opportunity in political ads, saying the vast majority of its revenue came from commercial, not political, ads. But lawmakers have noted that Facebook ads could be a focal point of Trump’s campaign as well as those of top Democrats.

Facebook’s hands-off ad policy has already allowed for misleading advertisements. In October, a Facebook ad from the Trump campaign made false accusations about Biden and his son, Hunter Biden. The ad quickly went viral and was viewed by millions. After the Biden campaign asked Facebook to take down the ad, the company refused.

“Our approach is grounded in Facebook’s fundamental belief in free expression, respect for the democratic process and the belief that, in mature democracies with a free press, political speech is already arguably the most scrutinized speech there is,” Facebook’s head of global elections policy, Katie Harbath, wrote in the letter to the Biden campaign.

In an attempt to provoke Facebook, Warren’s presidential campaign ran an ad falsely claiming that the company’s chief executive, Mark Zuckerberg, was backing the reelection of Trump. Facebook did not take the ad down.

Criticism seemed to stiffen Zuckerberg’s resolve. Company officials said he and Sheryl Sandberg, Facebook’s president, had ultimately made the decision to stand firm.

In a strongly worded speech at Georgetown University in October, Zuckerberg said he believed in the power of unfettered speech, including in paid advertising, and did not want to be in the position to police what politicians could and could not say to constituents. Facebook’s users, he said, should be allowed to make those decisions for themselves.

“People having the power to express themselves at scale is a new kind of force in the world — a Fifth Estate alongside the other power structures of society,” he said.

Facebook officials have repeatedly said significant changes to its rules for political or issue ads could harm the ability of smaller, less well-funded organizations to raise money and organize across the network.

Instead of overhauling its policies, Facebook has made small tweaks. Leathern said Facebook would add greater transparency features to its library of political advertising in the coming months, a resource for journalists and outside researchers to scrutinize the types of ads run by the campaigns.

Facebook also will add a feature that allows users to see fewer campaign and political issue ads in their news feeds, something the company has said many users have requested.

There was considerable debate inside Facebook about whether it should change. Late last year, hundreds of employees supported an internal memo that called on Zuckerberg to limit the abilities of Facebook’s political advertising products.

On Dec. 30, Andrew Bosworth, the head of Facebook’s virtual and augmented reality division, wrote on his internal Facebook page that, as a liberal, he found himself wanting to use the social network’s powerful platform against Trump.

But Bosworth said that even though keeping the current policies in place “very well may lead to” Trump’s reelection, it was the right decision. Dozens of Facebook employees pushed back on Bosworth’s conclusions, arguing in the comments section below his post that politicians should be held to the same standard that applies to other Facebook users.

For now, Facebook appears willing to risk disinformation in support of unfettered speech.

“Ultimately, we don’t think decisions about political ads should be made by private companies,” Leathern said. “Frankly, we believe the sooner Facebook and other companies are subject to democratically accountable rules on this, the better.”

2020 The New York Times Company

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Muslims attend church service in Kaduna to celebrate Christmas – TODAY

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Pastor Yohanna Buru, the General Overseer of Christ Evangelical and Life Intercessory Ministry Sabon Tasha-Kaduna, on Wednesday expressed delight at the large turnout of Muslims to celebrate Christmas with Christians in Kaduna.

Buru said: “I am so delighted that a large number Muslims that came to celebrate this year’s Christmas morning service with us.

“This will boost interfaith activities, promote religious tolerance and better understanding among different faith based organizations in the state and the northern region,” Buru said in an interview with reporters.

Buru expressed gratitude to what he described as “astonishing turn out of Muslim youth including their scholars at the church for Christmas service with such a large numbers of women Muslims and children, youth to promote peace and unity.

“The number of Muslims coming to attend Christmas service with us is increasing year-by-year as a result of better understanding and religious tolerance.”

Buru said : “it was really unbelievable to have such a large numbers of Muslims youth, top Islamic scholars, traditional title holders and various associations of peace promoting organizations from the 19 northern states to join us in this prayers, this is a clear fact that Nigerians can really be their brothers keepers.”

Earlier in his Sermon, Buru stressed the importance of promoting peaceful coexistence amongst different faith in Africa so as to strengthen peace and harmony.

He added that: “we must remember that we are from one family, because Adams and Eve were our original Biological parents. We all have that in our holy scriptures, the Bible and Qur’an.

“And we also believe in paradise and hell fire, therefore, we must be our brothers keepers, to live in peace and harmony.

“We are using the Christmas season to unite Muslims and Christians and to promote better understanding among different faith based organizations.

“I’m pleading with Muslims and Christians across the globe to use the season in promoting peace and unity and to forgive one another, so as to live in peace.

“Annually, hundreds of muslims usually come from parts of northern Nigeria to join us in christmas celebration.

“We are happy that large number of muslims from various places have again come and joined us in celebrating the birth of Jesus Christ.”

Responding on behalf of the muslim delegation from Funtua, Katsina state, Mallam Murtala Marafa, said ” we are really happy to be in your midst today because we came with other muslims from Kano, Sotoko and Zamfara to join in celebrating the birth of Jesus Christ,

“All muslims all over the world believe in Jesus Christ. We donated our offering like other Christians to promote peace and unity.

“It’s a season of peace and unity, so we are here to spread the message of peace and unity in the country,” he said.

Marafa said” we are Nigerians and we must join hands toward making this country great and as muslims, we must promote peace and unity, we must join hands toward making Nigeria a better place.

“Nigeria is a great country, lets join hands in praying for peace and unity for our country to prosper,” Marafa added.

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Safety violation/noise pollution: Lagos govt seals coy over controversial death of staff – Vanguard News

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Water Parks, 20 others too

By Olasunkanmi Akoni

The Lagos State Government has sealed off the premises of Multipak Nigeria Limited, a plastic production factory located at Plot F8, Kudirat Abiola Way, Oregun, Lagos for violation of safety rules and regulation as well as complete lack of safety management system.

In similar incidents, officials of the State Environmental Protection Agency, LASEPA, in its on going clampdown on noise pollution and determination to curb the menace of environmental nuisances across the state and further restore sanity and orderliness, on Saturday, shut over 20 facilities which included: Mosques, churches, Water Parks, Ikeja, West Gate Lounge, Omole, Magodo phase 1, among others for various environmental related issues.

The state government, through the State Safety Commission shut the production company, following the untimely death of one Mr Femi Olatunde, a factory worker who got his head stuck while operating one of the processing machines.

Director General, Lagos State Safety Commission, Lanre Mojola, stressed that the State Governor, Mr Babajide Sanwo-Olu’s administration has laid emphasis on safety of lives and property of its citizenry, hence, declaration of zero tolerance on factories and private organisations that violate health and safety rules and regulation.

ALSO READ: Man drowns in National Stadium swimming pool

According to Mojola, “On no account should any factory operate without putting in place safety measures at work places, good housekeeping, safety signage, firefighting and suppression equipment, good electrical wiring systems and a clean environment devoid of hazards to the lives of workers and visitors.”

He said that full investigation has commenced into the ugly incident to determine the immediate and remote cause of the death to prevent future occurrence.

Mojola added that investigation was also  ongoing with regards to safety infractions at another steel factory in Odonguyan, Ikorodu. “If they are found wanting after the investigation, the factory will be sealed and prosecuted fully in line with the extant law.

He therefore, urged organisations and individuals to embrace best practice in international safety operations to prevent fatal incidences that endanger lives, stressing, “safety of lives and property is our collective responsibility.”

The Lagos safety boss further warned factories and organizations that violators of safety rules would be severely sanctioned if found wanting.

On closure of religious houses and social centres over noise pollution, the exercise which cut across the state had others like: Skylouge Bar, Oko Oba, Mallam Garba Mosque, iloro, Dick Jockey outlets, Dopemu, Agege, Christ Embassy Church, Iyana ipaja ,El Castillo Homes, Abule Egba, others are Triple Z Hotel and Suite, Shasha, Akowonjo, Regia Luxuria Hotels & Suites, Alimosho, Kings of Diamonds, Coker, Barrel Louge, Opebi, Voice Of Elijah Christian Church, Ikeja, Celestial Church of Christ, Ilupeju and unnamed Mosque at Allhamdiyah all shut.

The General Manager, LASEPA, Dr Adedolapo Fasawe decried the frequent attacks on the officials and obstruction of same from carrying out their official duties by unidentified hoodlums hired by facility owners to prevent lawful application of the law.

Fasawe, however, warned the general public, particularly unrepentant noise polluters to desist from the act of attacking its officials while discharging their duties or face the full wrath of the Law.

This warning came on the heels of clamp down exercise embarked by the agency to curb the tide of noise pollution in the state.

She narrated how officials of the agency were attacked by hoodlums at the Westgate Louge, Omole and Sky Louge, Oko Oba while performing their duty to shut down the facilities for their persistent noise and failure to operate within the orbit of the law.

“Enforcing environmental law in our society that thrives on impunity will require enlisting maximum support of the members of the public, especially our clerics, opinion, political and market leaders to lend their voices to the campaign and condemn the unwarranted but coordinated attacks being launched on the officials while performing their duties,” she stated.

Fasawe further addressed the on-going insinuations and campaign of calumny against the agency by some mischief makers that particular religion was being targeted in the fight against noise pollution.

“Our operation devoid all religious coloration and no particular religion is targeted, our primary objective is to ensure decorum and sanity in the state. The Agency in the past months has being recording tremendous success and which must be supported by all rather than unwarranted attack of our intention by means of misinformation, misrepresentation and deliberate negative reports to bring the agency to disrepute and causes chaos amongst our people,” Fasawe charged.

She continued: “We have deployed various innovations and techniques to tackle environmental pollutions, especially in the area of noise pollution all to no avail, such as engaging the public through advocacy, social mobilisation programmes, stakeholder’s forum, Alternate Dispute Resolution (ADR) and lastly the use of enforcement as last resort in maintaining sanity.

“Voluntary compliance is more important to the agency than enforcement but regrettably our people doesn’t honour holistic path hence the need to use the provision of the law to curb the tide” she lamented.

Fasawe, also said that some facilities in Lagos were re-opened after complying with the directive of the agency.

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Early Rain Church Member Released From Chinese Prison

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A member of the Early Rain Covenant Church (ERCC) in Sichuan, China who was arrested last March by Chinese government officials was released last week.

After spending the last seven months in prison, Gou Zhongcan was on October 22, released and allowed to return home to Bazhou City, according to International Christian Concern.(ICC).

A Chinese Christian familiar with the case shared on Twitter on Oct. 23, “Brother Gou Zhongcan from ERCC in Chengdu, who was arrested in March earlier this year has returned home yesterday. Thanks be to God that the captive has been delivered!”

It has been reported that Gou’s vision deteriorated during the time of his incarceration. Jia Xuewei, another ERCC member, told the non-profit charity that otherwise he is in good health.

ICC says that Gou went missing on March 15, while he was visiting a friend in Zhejiang. His cellphone and computer were taken away from him. Three days later, he was spotted at the Hangzhou East Train Station being escorted by multiple plainclothes police officers. His head was shaved and he was handcuffed.

Since then, Gou’s lawyer has been unable to locate him despite multiple attempts. China Aid reported in July that Gou was detained and held in the basement of a public security bureau office for refusing to reveal the passwords to his computer and cell phone. When Gou’s elderly father was finally allowed to meet with him, he shared that his son did not look well, but that he had been singing hymns and worship songs while being detained.

Gou had already spent 10 years imprisoned due to his human rights work. At 23-years-old, he was a reporter and was imprisoned for reporting on the inhumane treatment of prisoners in China to human rights organizations abroad. He reportedly underwent severe torture during that time, chvnradio reports.

Gou came to Christ in 2016 after he was released, and began attending ERCC.

Bob Fu, president of ChinaAid says, that he’s thanking God for Gou’s release.

Thx God. Brother Gou Zhongcan from Early Rain Covenant Church was released after being incarcerated illegally by CCP regime for 7 months. He spent 10 years already for China human rights work previously. Pray for his recovery. https://t.co/9EatiUVsCV

— Bob Fu傅希秋 (@BobFu4China) October 24, 2019

Chinese Govt. Vows to Eliminate Christianity In China

Gina Goh, ICC’s Regional Manager for Southeast Asia, says, “What great news to know that Gou is finally free. But the Chinese government has not relented on the persecution of Christians. ERCC pastor Wang Yi and elder Qin Derfu are still criminally detained on trumped-up charges and their lawyers and family have not been able to see them, even after 10 months. We should continue to put pressure on Beijing so that they will be set free. None of them deserved imprisonment in the first place.”

China is ranked 27th on Persecution Watchdog, Open Door’s list of top 50 countries where it is most deadly to be a christian.

The post Early Rain Church Member Released From Chinese Prison appeared first on Believers Portal.

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Senator Dino Melaye joins Nollywood | P.M. News

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Dino Melaye

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Senator Dino Melaye joined Nollywood just few hours after the Appeal Court affirmed the decision of the Kogi Election Petition Tribunal nullifying his victory.

The outspoken senator will be featured as one of the key actors, in a Television series titled ‘Equity unbound,” an idea of the Pillars of Hope African Initiative (POHAI).

Other prominent actors including Linc Edochie, Victor Decke, Chief Bruno Iwuola and Paul Sambo will also be featured in the TV series.

Addressing a world press conference, the Country Director of POHAI, Chinyere Onyemekara, said the main focus of the project is on ‘equal rights and sociai justices in Africa,’ using Nigeria as a case study.

“Equity unbound TV series is a soap opera that holistically ex-ray the quality of justice system in Nigeria and its attendant effect on both the masses, the elites and the government.

“It is a mind-blowing expository drama presentation of the human rights challenges of an ordinary common Nigerian. A good example of the issues treated in this series is the recent report by BBC, on the pervasive threat of “sax for grades and sex for Marks” in Nigeria’s institutions of learning.

“A 120mins pilot episode of Equity unbound TV series has been shot with so many celebrity Actors and with state of the art equipment cum professionais and highly motivated crew.

“The idea of this is to use drama as an effective tool of communication to correct the ills and promote an acceptable social justice system in Nigeria.

“Gentlemen of the press, you will agree that Africa and Nigeria in particular is far behind in terms of perfect justice system and equitable society.

“We at POHAI has taken it upon ourselves to expose these shortcomings for the purpose of strategic attention and correction:

“We hereby call on members of the fourth estate of the realm, civil society groups, the international community, cooperate organizations, Nigerian government at all levels and well-meaning Nigerians to support in whatever way possible to bring this humanitarian project to fruition,” Onyemekara stated.

Speaking on why he joined the drama, Senator Dino Melaye, expressed happiness to be part of the series that will expose unjust act in the society.

Melaye said: “I’m happy to have participated in the series, especially as it will help correct social problems in the country. I am not a greenhorn in acting because I emerged as the best actor during my NYSC program.

“I am ready to serve this country in any capacity and I feel that participating in the series is another way of contributing my quota in correcting the social ills in Nigeria.

“If I have such opportunity again I won’t hesitate to take it,” Melaye stated.

The drama’s director said that Senator Dino Melaye acted the role of Joshua in the series, which is an assemblage of professional actors and politicians.

“The drama is all about tackling social vices in the society. The drama, he said captures such issues like corruption, injustice, bad governance and so on.”

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Melaye makes Nollywood debut in ‘Equity Unbound’ – TheCable Lifestyle

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Dino Melaye, embattled lawmaker representing Kogi west senatorial district, has made his Nollywood debut in ‘Equity Unbound’, a television series, alongside other prominent actors. 

The Kogi-born politician and senator was on Friday unveiled as lead character of the film, hours after

Melaye is expected to feature alongside Dan Nwanyanwu, the national chairman of the Zenith Labour Party (ZLP), and other notable Nollywood actors like Bruno Iwuoha, Linc Edochie, Victor Decke, Paul Sambo in the series.

‘Equity Unbound’ is an idea of the Pillars of Hope African Initiative (POHAI).

Speaking about the project, Chinyere Onyemekara, the country director of POHAI, said the main focus of the movie is on “equal rights and social justices in Africa”, using Nigeria as a case study.

#Dinotheactor unperturbed by today’s Appeal Court Ruling, @dino_melaye attends the unveiling of Equity Unbound, a movie series he starred in.#BuhariWedding #PresidentialWedding #dinomelaye #FridayMotivation pic.twitter.com/csntArlpfy

— ofimkofim (@ofimkelechiofim) October 11, 2019

“Equity unbound TV series is a soap opera that holistically ex-ray the quality of justice system in Nigeria and its attendant effect on both the masses, the elites and the government,” she said.

“It is a mind blowing expository drama presentation of the human rights challenges of an ordinary common Nigerian. A good example of the issues treated in this series is the recent report by BBC, on the pervasive threat of “sax for grades and sex for Marks” in Nigeria’s institutions of learning.

“A 120mins pilot episode of Equity unbound TV series has been shot with so many celebrity Actors and with state of the art equipment cum professionais and highly motivated crew.

“The idea of this, is to use drama as an effective tool of communication to correct the ills and promote an acceptable social justice system in Nigeria.

“Gentlemen of the press, you will agree that Africa and Nigeria in particular is far behind in terms of perfect justice system and equitable society.

“We at POHAI has taken it upon ourselves to expose these shortcomings for the purpose of strategic attention and correction:

“We hereby call on members of the fourth estate of the realm, civil society groups, the international community, cooperate organizations, Nigerian government at all levels and well-meaning Nigerians to support in whatever way possible to bring this humanitarian project to fruition.”

On his part, Melaye said he was elated to be part of a project that would expose unjust act in the society.

“I’m happy to have participated in the series, especially as it will help correct social problems in the country. I am not a greenhorn in acting because I emerged as the best actor during my NYSC program,” he said.

“I am ready to serve this country in any capacity and I feel that participating in the series is another way of contributing my quota in correcting the social ills in Nigeria.

“If I have such opportunity again I won’t hesitate to take it.”

In the 120-minute TV series, the legislator is expected to assume the role of Joshua, which is an assemblage of professional actors and politicians.

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