Five new laws that could affect your rights at work in 2020 – Somerset Live

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The year 2020 is set to see a range of new laws come into effect.

Here are five key employment law changes that could affect you at work, as explained by Abigail Hubert of Birketts LLP to The Gazette.

From how holiday pay is calculated – to the leave you can expect when you are grieving – these are worth knowing.

Improved rights for agency workers

‘Swedish Derogation,’ also known as ‘pay between assignments’ contracts would previously see agency workers agree a contract that would remove their rights to equal pay with permanent counterparts after 12 weeks working on the same assignment.

From April 6, these will no longer be permissible and agency workers who have been in their employment for 12 weeks will be entitled to the same pay as those on permanent contracts.

Agency workers will have more rights

As well as this, all agency workers will be entitled to a key information document that more clearly sets out their employment relationships and terms and conditions with their agency.

Agency workers who are considered to be employees will be protected from unfair dismissal or suffering a detriment if the reasons are related to asserting rights associated with The Agency Worker Regulations.

Holiday pay calculations changing

From April 6, the reference period to calculate a ‘week’s pay’ for holiday pay purposes will be extended from the previous 12 weeks of work to the previous 52 weeks.

This could affect employees who work variable hours seasonally.

New parental bereavement leave

In September 2018, a new workplace right for paid leave to be given to bereaved parents was officially enshrined in law.

The first of its kind in the UK, the Parental Bereavement Leave and Pay Act 2018 is expected to come into force in April 2020 and will give employed parents the right to two weeks leave if they lost a child under the age of 18 or suffer a stillbirth from 24 weeks of pregnancy.

Employed parents will also be able to claim pay for this period, subject to meeting eligibility criteria.

New right to a written statement of terms

Currently, employees who have been continuously employed for more than one month must be provided with a written statement of terms within two months of employment commencing.

From April 6, all new employees and workers will have the right to a statement of written particulars from their first day of employment. Additional information will have to be included as part of the extended right.

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Accountability for tax shifting

At present, the IR35 rules apply where an individual personally performs services for a client through an intermediary. If the services were provided under a direct contract, the worker would be regarded for tax purposes as being employed by the client.

Currently, it is the intermediary’s responsibility to determine whether IR35 applies.

From April 6, changes to IR35 rules will be implemented for medium and large businesses in the private sector and will largely mirror changes that took effect in the public sector in 2017.

Under the new regime, for all contracts entered into, or payments made on or after April 6, the onus will shift from the intermediary to the end user client to make a status determination.

Responsibility for accounting for tax and national insurance will shift to the party who pays for the individual’s services, known as the ‘fee-payer.’

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

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

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

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

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

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

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

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

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

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

Sunderland Royal Hospital

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Northumbria Specialist Emergency Care Hospital, in Cramlington, Northumberland

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

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

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

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

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

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

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

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

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

City Hospitals Sunderland (South Tyneside & Sunderland)

Labour and birth – 9.2/10 – About the same

Staff – 9.3/10 – Better

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

County Durham and Darlington NHS Foundation Trust

Labour and birth – 8.9/10 – About the same

Staff – 8.8/10 – About the same

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

Gateshead Health NHS Foundation Trust

Labour and birth – 8.8/10 – About the same

Staff – 8.6/10 – About the same

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

Northumbria Healthcare NHS Foundation Trust

Labour and birth – 8.9/10 – About the same

Staff – 8.8/10 – About the same

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

The Newcastle upon Tyne Hospitals NHS Foundation Trust

Labour and birth – 9.4/10 – Better

Staff – 9.3/10 – Better

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SUPPLIED/SARAH BRYANT
Bella and her pups.

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

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

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

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

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

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

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

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

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

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

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

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

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

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Parents beat, starve 18-year-old daughter to death for dating Yoruba boy | Theinfong

person

An 18-year-old girl, Amaka Nweke, has reportedly been beaten to death by her parents for dating a Muslim Yoruba boy and having a baby for him in Lagos.

According to The New Telegraph, she was allegedly beaten to death by her parents, Mr. and Mrs. Mike Nweke, for dating and having a baby for a Muslim Yoruba boy in Agility, Mile 2 in Lagos.

The Lagos State Police Command has said it is waiting for medical report to ascertain the cause of her death, although, angry residents of Agility, Mile 12 claim her parents repeatedly subjected Amaka to torture, including starving her during pregnancy.

Amaka and her boyfriend, Ibrahim Lawal, were said to have met when she was in Senior Secondary School. The relationship later resulted into pregnancy, which her parents kicked against. She later delivered a baby boy, christened Zaeed.

Her friends claim Amaka went through hell while pregnant for defying her parents.

One of the Nwekes’ neighbours, Adebola, said;

“Amaka went through a lot. She really suffered. When they were dating, her parents were always threatening her.

They told her that they didn’t want her to continue associating with the boy. They used to beat her with different objects even while she was pregnant. Whenever her boyfriend brought food to her, they would not allow her to have access to it.”

When Amaka was delivered of her baby, her parents couldn’t afford the medical bill. They had to call on Ibrahim’s family and they gladly paid up.

After she was released from the hospital, her parents tried to prevent the boy’s family from naming their grandchild. But it took the intervention of the Chairman of the Community Development Association (CDA) and some elders in the area before the Nwekes released the baby to them.

Ibrahim’s mother, Ebunola, said that she reported the repeated beatings to the police. She said:

“When my son impregnated Amaka, I didn’t reject the pregnancy.

I was already used to seeing them together. On January 1, 2020, she called Ibrahim that her mother had started beating her again for collecting clothes and money from us. .

It was during the beating that she became unconscious and later confirmed death at the #Gbagada General Hospital.”

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Parents beat 18-year-old daughter to death for dating Yoruba boy (Photo)

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Parents beat their 18-year-old daughter to death for dating a Muslim Yoruba boy and having a baby for him in Lagos.

The Police are currently investigating the death of an 18-year-old girl, Amaka, who was allegedly beaten to death by her parents, Mr. and Mrs. Mike Nweke, for dating and having a baby for a Muslim Yoruba boy in Agility, Mile 2 in Lagos, New Telegrph reports.

The Lagos State Police Command has said it is waiting for medical report to ascertain the cause of her death, although, angry residents of Agility, Mile 12 claim her parents repeatedly subjected Amaka to torture, including starving her during pregnancy.

Amaka and her boyfriend, Ibrahim Lawal, were said to have met when she was in Senior Secondary School. The relationship later resulted into pregnancy, which her parents kicked against. She later delivered a baby boy, christened Zaeed.

Her friends claim Amaka went through hell while pregnant for defying her parents.

One of the Nwekes’ neighbours, Adebola, said;

“Amaka went through a lot. She really suffered. When they were dating, her parents were always threatening her.

They told her that they didn’t want her to continue associating with the boy. They used to beat her with different objects even while she was pregnant. Whenever her boyfriend brought food to her, they would not allow her to have access to it.”

When Amaka was delivered of her baby, her parents couldn’t afford the medical bill. They had to call on Ibrahim’s family and they gladly paid up.

After she was released from the hospital, her parents tried to prevent the boy’s family from naming their grandchild. But it took the intervention of the Chairman of the Community Development Association (CDA) and some elders in the area before the Nwekes released the baby to them.

Ibrahim’s mother, Ebunola, said that she reported the repeated beatings to the police. She said:

“When my son impregnated Amaka, I didn’t reject the pregnancy.

I was already used to seeing them together. On January 1, 2020, she called Ibrahim that her mother had started beating her again for collecting clothes and money from us. .

It was during the beating that she became unconscious and later confirmed death at the #Gbagada General Hospital.”

Follow us on Facebook – @Lailasnews; Twitter – @LailaIjeoma for updates

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Woman who married in 1984 gives birth to first child | P.M. News

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Mr Christopher Osiebo and wife Dorcas with baby Emmanuel (The Nation)

A 58-year-old woman, Mrs Dorcas Osiebo, who stopped menstruating in 2006 without a trace of pregnancy, has been delivered of a baby boy.

Dorcas, who delivered the baby on 13 Dec in Abuja, said that she was confused and excited when her Pastor’s wife, a nurse confirmed her pregnancy.

“She (nurse) looked at my face and said, ‘Mummy, to God be the glory, you are pregnant”. I was very surprised”.

Dorcas got married to Mr Christopher Osiebo, now 64 years old, with both hoping to have a child in their 35-year-old union.

“But early this year (2019), I just felt in my body as if I was pregnant, but I thought how can that be especially when I have not seen my period since 2006,” she said.

“I got married in January 1984, but there was no child at all; people who got married the same year with us have children; even my immediate younger sister has grand-children,” Dorcas said.

She said they sought help from both the traditional and orthodox medical practices but there was no respite.

According to her, she entered menopause in 2006, and her younger sister, who got married after her, is already a grandmother.

“I drank a lot of concoctions (herbal mixtures) in my effort to get pregnant.

“One of the concoctions, I cannot withstand the smell; to drink it; I will block my nose, and close my eyes before I can drink it.

“I did all these to make things better for me but nothing good came out of it,” she said.

“We have gone to many places and hospitals that we cannot even number them all. In 2006, my husband took me for scanning at a hospital in Jos and obstruction was discovered (not fibroid).

“An operation was carried out at the hospital and I came back home but no solution, rather, since the operation was carried out, I didn’t see my period again.

“When I told my husband, he didn’t believe I was pregnant. But I discovered that I no longer like to eat my best foods and my clothes no longer size me,” she explained.

While her period of waiting for a child lasted, she said: “None of my in-laws disturbed me. My late father-in-law did not disturb me, although he once asked why we were just folding our arms and doing nothing about the situation.

“We then told him that we were not folding our arms but trying our best, but that the thing never worked out.

“But I and my husband were worried. My husband is the firstborn of his father and I am the first of mine also.

“We have younger ones who already have good number of children but it is only us that did not have children of our own. Whenever we remembered all these, we were not happy,” she said.

However, Mr Osiebo said after a long period of marriage and prayer without a child he decided to depend on God for a miracle.

“But by the grace of God today, a baby boy has entered this family; that is the cause of my joy. I am very happy, thank God,” said the excited husband.

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Grace Ajilore is pregnant – Shocked Nigeria twitter users react

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Nigeria News | Laila’s Blog
Grace Ajilore is pregnant – Shocked Nigeria twitter users react

Following the announcement of her pregnancy, Nigerian vlogger Grace Ajilore has caused a stir on social media.

Mixed reactions as Grace Ajilore announces pregnancy
Mixed reactions as Grace Ajilore announces pregnancy

While some have congratulated her for getting set to start a family, some Twitter users are accusing her of hypocrisy, shocked, that the woman who has been preaching that ‘men are trash’ could become pregnant.

The vlogger who is known for her videos in which she advises ladies on knowing their self-worth and not settling for men who mistreat them, left many people pleasantly surprised and others in shock with the news of her pregnancy.

The vlogger who is currently trending online is being dragged for apparently what many people believe is her misleading women into thinking all men are bad for them.

See her post below:

See some reactions from Twitter:

https://twitter.com/Grace_jobi/status/1206290873438363648

Popular Band leader of “ Men are scum “ group Grace Ajilore has reportedly ‘fell pregnant’
Rumor has it that she found her own golden trash can #Grace pic.twitter.com/QjXBmFuy65

— NANOSCROLL 📜 (@nanoscrollng) December 15, 2019

Me after seeing grace ajilore the leader of “be wicked to men” is pregnant. https://t.co/fIPR8gzuyn

— ‘CHEF ASIYA’. (@Asiya_aliyu_) December 15, 2019

Linda Ikeji preached celibacy so tey, she FELL pregnant, Glory Osei was forming feminist that hates men only to realize that she is married. Now, Grace Ajilore that is always setting standards and screaming “Men are scum” is pregnant. The internet is a very interesting place.

— Upcoming fashion designer. (@EllabyOJ) December 15, 2019

Grace Ajilore too is pregnant???
I thought she’s a virgin.
Team No Penis needs to explain whats going on in their camp.

— B h a d o o s k y (@BhadmusAkeem) December 16, 2019

However there are others defending her online:

If u’ve been watching Grace Ajilore on IG with her facial expressions, accents & goofiness yet still came to the conclusion that she’s a bitter woman who hates men, then ur brain is probably filled with hair relaxer.

That lady that reminds me of Bovi?
Lol, u twitter pple are mad

— Adunni Adaora Achebe (@Adunni_Achebe) December 16, 2019

Grace Ajilore didn’t sha say men are scum. She said do not be with men who treat you like trash, who don’t care about you and who don’t treat you right.
Y’all carried it as men are scum because that’s how plenty of you are or that’s how the men in your life are.

— Chemical Brother 👌 (@chemicalbrodar) December 16, 2019

Grace Ajilore didn’t sha say men are scum. She said do not be with men who treat you like trash, who don’t care about you and who don’t treat you right.
Y’all carried it as men are scum because that’s how plenty of you are or that’s how the men in your life are.

— Chemical Brother 👌 (@chemicalbrodar) December 16, 2019

Grace Ajilore specifically said don’t be with a man who does not care about you. Fling him in the bin specifically. https://t.co/mmjU6Onz9V

— 𝓤 (@UnravelingwithR) December 15, 2019

Grace Ajilore didn’t say don’t fall in love or whatever
She said “know who u’re giving ur time to, don’t settle, place value on urself & set standards.”
She talks about her man in her vlogs.I don’t know what all this ruckus is about now that she’s pregnant.
Must one marry to….

— (Tough Cookie) Phoenix (@TheHadassahh) December 15, 2019

If you’re dragging Grace Ajilore coz you think her videos are bitter and man hating, there are two things involved-

-Your head is paining you, no oil, dry sense of humour.

-You were so desperate for anyone to validate your man hatred so you picked her as your Queen.

— Sansa Stark (@_Oroboghene) December 16, 2019

Wanna know grace ajilore like i just did..This is one of her videos bcuz when i see bitter,i condemn it bt this babe right here is all bantsss pic.twitter.com/SKSghxNxp3

— mama_mia (@olori_Abeke) December 15, 2019

Grace Ajilore is pregnant – Shocked Nigeria twitter users react
Ifeanyi Ngerem

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Woman gives birth to quintuplets after 16 years of childlessness

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It is the joy of every woman to be called a mother after marriage. for many that expectant joy could become instantly traumatic when the fruit of the womb isn’t forthcoming after years of marriage.

For 44-year-old Mrs Susan Egenti, her joy knew no bounds when she delivered quintuplets after 16 years of marriage. She was delivered of the babies at the Federal Medical Centre, Jabi, Abuja.

Mrs Susan Egenti an indigene of Nando, in Anambra East Local Government Area of Anambra State was delivered through a caesarean section on November 6, 2019. The quintuplets three boys and two girls were still in the Intensive Care Unit (ICU) of the hospital when our reporters visited on Thursday afternoon, though the nurses looking after them said they were hale and hearty.

They stated that four of the babies were born healthy, measuring the average weight of a newborn, except one who was underweight and was weighed 1.9 Kg. Speaking to Daily Trust on Saturday on her hospital bed, Mrs Egenti said within her 16 years of marriage, she had taken all medical options (except IVF) to get a baby but to no avail until she had the quintuplets.

She said she resorted to traditional/herbal remedies to conceive a child but that was also futile, leaving her in perpetual despair. She described the birth of her babies as an enormous blessing from God as it was her first and only pregnancy since she got married in 2003. “I have been married since 2003 with no children, not even to get pregnant and have a miscarriage. Every time we attend a child dedication either in our church or elsewhere, I always come home crying, praying for the day God will have mercy on me and grant me the fruit of the womb.” She narrated that the birth of the babies almost took her life as she underwent two different operations, after the delivery, to stop the internal bleeding she suffered.

She stressed that the last operation one left her in a coma for about five days. Mrs Susan who lives with her husband in a room self-contained apartment in Utako village says she sells plastic containers while her husband manages a small chemist at Jabi park.

According to her, she has spent all her meagre resources on medical expenses and as such, they are left with nothing to cater for the five children, calling on Government and philanthropic Nigerians to assist them.

Her husband, Mr Emmanuel Nnamdi Egenti, who also spoke to our reporters at his one-bedroom accommodation in Utako village, an urban slum in the heart of Utako District, expressed joy over the birth of his quintuplets, saying even during their years of childlessness, they had never given up, but rather, put their hope in God, as there was nothing he could do.

However, he said they were yet to pay for the hospital bills even though the babies have been discharged but their mother is very ill and can’t even stand on her feet. He prays for the government’s intervention to enable then take care of the babies, adding that they would not be having any more babies in the future.

“We are grateful to God for what he has done for us. He has proven that He is the one and only true God, who answers prayers of those who call on Him,” he said, stressing that the because they were poor, the prospect of looking after the children in terms of feeding, clothing, education and healthcare was so bleak that their joy at having the babies was almost, immediately, turning into despair and despondency.

Dr. Tochukwu Nwoye, the medical doctor who led a team of doctors that carried out the operation, was not on seat when our reporters visited the hospital. The new mother of five who couldn’t hide her despair on how to foot the bills and subsequently take care of her new bundle of joy was kept in a semi-private ward away from her babies as she was still recuperating from the operations.

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Woman Gives Birth To Quintuplets After 16 Years Of Childlessness – YabaLeftOnline

person

It is the joy of every woman to be called a mother after marriage. for many that expectant joy could become instantly traumatic when the fruit of the womb isn’t forthcoming after years of marriage.

For 44-year-old Mrs Susan Egenti, her joy knew no bounds when she delivered quintuplets after 16 years of marriage. She was delivered of the babies at the Federal Medical Centre, Jabi, Abuja.

Mrs Susan Egenti an indigene of Nando, in Anambra East Local Government Area of Anambra State was delivered through a caesarean section on November 6, 2019. The quintuplets three boys and two girls were still in the Intensive Care Unit (ICU) of the hospital when our reporters visited on Thursday afternoon, though the nurses looking after them said they were hale and hearty.

They stated that four of the babies were born healthy, measuring the average weight of a newborn, except one who was underweight and was weighed 1.9 Kg. Speaking to Daily Trust on Saturday on her hospital bed, Mrs Egenti said within her 16 years of marriage, she had taken all medical options (except IVF) to get a baby but to no avail until she had the quintuplets.

She said she resorted to traditional/herbal remedies to conceive a child but that was also futile, leaving her in perpetual despair. She described the birth of her babies as an enormous blessing from God as it was her first and only pregnancy since she got married in 2003. “I have been married since 2003 with no children, not even to get pregnant and have a miscarriage. Every time we attend a child dedication either in our church or elsewhere, I always come home crying, praying for the day God will have mercy on me and grant me the fruit of the womb.” She narrated that the birth of the babies almost took her life as she underwent two different operations, after the delivery, to stop the internal bleeding she suffered.

She stressed that the last operation one left her in a coma for about five days. Mrs Susan who lives with her husband in a room self-contained apartment in Utako village says she sells plastic containers while her husband manages a small chemist at Jabi park.

According to her, she has spent all her meagre resources on medical expenses and as such, they are left with nothing to cater for the five children, calling on Government and philanthropic Nigerians to assist them.

Her husband, Mr Emmanuel Nnamdi Egenti, who also spoke to our reporters at his one-bedroom accommodation in Utako village, an urban slum in the heart of Utako District, expressed joy over the birth of his quintuplets, saying even during their years of childlessness, they had never given up, but rather, put their hope in God, as there was nothing he could do.

However, he said they were yet to pay for the hospital bills even though the babies have been discharged but their mother is very ill and can’t even stand on her feet. He prays for the government’s intervention to enable then take care of the babies, adding that they would not be having any more babies in the future.

“We are grateful to God for what he has done for us. He has proven that He is the one and only true God, who answers prayers of those who call on Him,” he said, stressing that the because they were poor, the prospect of looking after the children in terms of feeding, clothing, education and healthcare was so bleak that their joy at having the babies was almost, immediately, turning into despair and despondency.

Dr. Tochukwu Nwoye, the medical doctor who led a team of doctors that carried out the operation, was not on seat when our reporters visited the hospital. The new mother of five who couldn’t hide her despair on how to foot the bills and subsequently take care of her new bundle of joy was kept in a semi-private ward away from her babies as she was still recuperating from the operations.

Source: Daily Trust

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