When and where you can see a historic steam train travel through Cambs – Cambridgeshire Live

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A historic steam train will be travelling through a part of Cambridgeshire this year, giving train buffs a chance to see the iconic locomotive.

Ely station will be treated to a rare sighting of one of only two surviving B1 class locomotives.

The train will be passing through the station on April 11, 2020, on its journey from London to Lincoln – where passengers will enjoy a day out in the cathedral city.

The 63106 Mayflower will also be passing through several other nearby stations including Ipswich and Bury St Edmunds (as well as others listed below).

Steam train enthusiasts can buy tickets to ride it to Lincoln, or simply visit the stations it passes through to catch a glimpse of the magnificent machine.

Find out more about timings and the train’s exciting history below.

About the engine

Abigail Rabbett

As reported by our sister title EssexLive, the 63106 Mayflower is one of only two surviving B1 Class locomotives, designed to haul either express passenger trains or freight traffic.

She was built in 1948 by the North British Locomotive Company in Glasgow and first deployed in Hull, before being transferred to Bradford.

Mayflower was the last B1 in service, with her final trip spent hauling the ‘Yorkshire Pullman’ from Leeds in September 1967.

The train was restored in the 1970s, acquired by Steam Dreams owner David Buck in 2014 ad returned to mainline service in 2015, before being withdrawn for an extensive overhaul.

Where can you see it?

Here are the times the train will be passing in and out of Ely and nearby stations on its journey:

For more information and tickets for the journey, visit the Steam Dreams website.

Follow Social Media Editor Abigail Rabbett on social media

To follow Abigail on Twitter, click here.

To like her Facebook page and keep up to date with the latest breaking news, press here.

Or simply visit Cambridgeshire Live’s main Facebook page here for all our latest stories.

Related posts

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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Girl, 4, mistaken for toddler due to rare disease affecting just 30 people worldwide – Mirror Online

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A four-year-old girl is often mistaken for a toddler due to a rare disease affecting just 30 people worldwide.

Violet Cocking still wears clothes designed to fit an 18 month old – and is only a few inches taller than her four-month-old sister, Ada.

Mum Charlotte Cocking, 32, was concerned about her size from birth, but says medics were unable to find a cause for two and a half years.

But after months of turmoil, a genetic test revealed Violet from St. Ives, Cornwall, had microcephalic osteodysplastic primordial dwarfism type 1 – a genetic condition inherited from both parents.

Charlotte and her husband Robert, 43, unknowingly carried the dwarfism gene which meant Violent inherited the same defective gene from both.

Ada

Charlotte, who is a bartender said: “People assume Violet is a toddler so when I tell them her real age, they look at me with a very confused expression.

“Violet has settled well into reception but requires extra support – she has a really good friend called Willow who looks out for her.

“She is 3ft 8in, a foot taller than Violet, which is a pretty average height for a four-year-old but their height doesn’t stop them from being the best of friends.”

Violet was born at 36 weeks yet she looked smaller than ever and weighed 2lb 15oz.

Charlotte added: “She was kept in NICU as she was unable to feed and could only stomach 50ml of milk a day – the equivalent to a double shot in barmaid terms.

“As the months passed, she barely grew, and I became very concerned that she was wearing newborn clothing at six-months-old.

“She wasn’t much bigger than a pint glass at three-months old.

age
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“Even now she wears specially made shoes which are a size two and a half for babies.

“But periodically she was fine, we had genetic and blood tests with the NHS but the results were never abnormal – but I knew something was wrong.

“I researched the living hell out of her characteristics – she had curved fingers and puffy feet along with a really small head.

“Dwarfism always popped up in a search, but I assumed I was being daft until we had another test that involved a saliva swab from me, Rob and Violet, when she was two and a half.

“We were over the moon to finally a diagnosis that revealed she has a rare form of an already rare form of dwarfism.”

The couple discovered a charity called ‘Walking with the Giants’ who have a specialist genetic team that has diagnosed five other children with Violets condition in the UK.

All

There was a 50 per cent chance Violet would be a carrier like each of her parents and a 25 per cent chance to not have the condition.

Violet is still currently reaching all her milestones and despite her development being delayed, she did learn how to walk seven months ago.

Charlotte said: “I can’t help but feel like I wasted the first year of Violet’s life obsessing with what is wrong with her.

“I feel guilty, but I was desperate to get an answer which is when I came across the charity Facebook group.

“I can’t thank them enough for their support and it is nice to be able to speak to other parents who have children with a rare form of dwarfism.

“We don’t know what to expect for the future, but she is very lucky as other children with this condition are known to be severely disabled.

Babies

“Violet isn’t a typical child, but she is smart and funny – she is mentally three-years-old.

“Her speech is behind and can be hard for others to understand and she can only walk a short distance in places where she is familiar with.”

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Top news stories from Mirror Online

Charlotte feared her second daughter Ada, now four months, may have the same condition but a Chorionic villus sampling at 11 weeks confirmed she was born without.

She adds: “I was a nervous wreck waiting for the results with Ada, as we wouldn’t be able to cope with another disabled child.

“It was great when they said she was unaffected and already Ada is almost as big as Violet.

“But that doesn’t stop her from being the best big sister and she always bringing Ada her toys.”

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Coronavirus spreads to more than 800 in China: First death outside epicentre | Stuff.co.nz

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China’s National Health Commission said Friday afternoon (NZ time) the confirmed cases of the new coronavirus had risen to 830 with 25 deaths.

The first death was also confirmed outside the central province of Hubei, where the capital, Wuhan, has been the epicentre of the outbreak.

The health commission in Hebei, a northern province bordering Beijing, said an 80-year-old man died after returning from a two-month stay in Wuhan to see relatives.

The vast majority of cases have been in and around Wuhan or people with connections the city. Other cases have been confirmed in the United States, Japan, Taiwan, South Korea and Thailand. Singapore and Vietnam reported their first cases Thursday, and cases have also been confirmed in the Chinese territories of Hong Kong and Macau.

Many countries are screening travellers from China for symptoms of the virus, which can cause fever, coughing, breathing difficulties and pneumonia.

The World Health Organisation has decided against declaring the outbreak a global emergency, a step that can bring more money and resources to fight a threat but that can also cause trade and travel restrictions and other economic damage, making the decision a politically fraught one.

The decision “should not be taken as a sign that WHO does not think the situation is serious or that we’re not taking it seriously. Nothing could be further from the truth,” WHO Director General Tedros Adhanom Ghebreyesus said. “WHO is following this outbreak every minute of every day.”

The coronaviruses are a family of viruses that originate in animals before making the jump to humans.

Chinese authorities moved to lock down at least three cities with a combined population of more than 18 million in an unprecedented effort to contain the deadly new virus that has sickened hundreds of people and spread to other parts of the world during the busy Lunar New Year travel period.

Chinese officials have not said how long the shutdowns of the cities will last. While sweeping measures are typical of China’s Communist Party-led government, large-scale quarantines are rare around the world, even in deadly epidemics, because of concerns about infringing on people’s liberties. And the effectiveness of such measures is unclear.

“To my knowledge, trying to contain a city of 11 million people is new to science,” said Gauden Galea, the WHO”s representative in China. “It has not been tried before as a public health measure. We cannot at this stage say it will or it will not work.”

GETTY IMAGES
People wear face masks as they wait at Hankou Railway Station in Wuhan

Jonathan Ball, a professor of virology at molecular virology at the University of Nottingham in Britain, said the lockdowns appear to be justified scientifically.

“Until there’s a better understanding of what the situation is, I think it’s not an unreasonable thing to do,” he said. “Anything that limits people’s travels during an outbreak would obviously work.”

But Ball cautioned that any such quarantine should be strictly time-limited. He added: “You have to make sure you communicate effectively about why this is being done. Otherwise you will lose the goodwill of the people.”

GETTY IMAGES
A resident wears a mask to buy vegetables in the market in Wuhan.

During the devastating West Africa Ebola outbreak in 2014, Sierra Leone imposed a national three-day quarantine as health workers went door to door, searching for hidden cases. Burial teams collecting corpses and people taking the sick to Ebola centres were the only ones allowed to move freely. Frustrated residents complained of food shortages.

In China, the illnesses from the newly identified coronavirus first appeared last month in Wuhan, an industrial and transportation hub. Local authorities demanded all residents wear masks in public places and urged civil servants wear them at work.

After the city was closed off Thursday, images showed long lines and empty shelves at supermarkets, as people stocked up. Trucks carrying supplies into the city are not being restricted, although many Chinese recall shortages in the years before the country’s recent economic boom.

Analysts predicted cases will continue to multiply, although the jump in numbers is also attributable in part to increased monitoring.

KEVIN FRAYER/GETTY IMAGES
A Chinese passenger that just arrived on the last bullet train from Wuhan to Beijing is checked for a fever by a health worker at a Beijing railway station.

“Even if (cases) are in the thousands, this would not surprise us,” the WHO’s Galea said, adding, however, that the number of infected is not an indicator of the outbreak’s severity so long as the death rate remains low.

The coronavirus family includes the common cold as well as viruses that cause more serious illnesses, such as the SARS outbreak that spread from China to more than a dozen countries in 2002-03 and killed about 800 people, and Middle Eastern respiratory syndrome, or MERS, which is thought to have originated from camels.

China is keen to avoid repeating mistakes with its handling of SARS. For months, even after the illness had spread around the world, China parked patients in hotels and drove them around in ambulances to conceal the true number of cases and avoid WHO experts. This time, China has been credited with sharing information rapidly, and President Xi Jinping has emphasised that as a priority.

Health authorities are taking extraordinary measures to prevent the spread of the virus, placing those believed infected in plastic tubes and wheeled boxes, with air passed through filters.

The first cases in the Wuhan outbreak were connected to people who worked at or visited a seafood market, now closed for an investigation. Experts suspect that the virus was first transmitted from wild animals but that it may also be mutating. Mutations can make it deadlier or more contagious.

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Review: Marlins Brewhouse: The most interesting restaurant in Estero

Fort Myers restaurant reviews: The most interesting restaurant in Estero? Marlins Brewhouse


Jean Le Boeuf


JLEBOEUF@NEWS-PRESS.COM
Published 11:00 AM EST Jan 16, 2020

The bowl of ramen came on the same tray as my IPA. 

Painted in a dainty teal print, the bowl cradled a trove of add-ins, from the traditional (wavy wheat noodles, herbs, soft-boiled eggs, glistening hunks of chashu pork belly) to the wholly untraditional (braised collard greens, fat chicken wings).

A French press, the kind used for morning coffee, sat next to the dish, filled with a murky, mahogany-hued broth. Our server pushed the plunger, pressing the aromatic bits of onion and garlic to the bottom, clear of the spout. He poured the broth into my bowl, set my IPA at its side, then went back to his beer-toting duties, leaving me slack-jawed and frozen in awe. 

What the how?!

The French Pressed Ramen ($14) is a shockingly delicious stunner from Marlins Brewhouse in Estero. This fusion take is loaded with braised collards, noodles, soft-boiled eggs, chashu and four chewy-crisp chicken wings. It’s finished with a murky, rich broth that’s pressed and poured table-side. It’s possibly the last thing you’d expect from a taproom.
Special to The News-Press

I’d been to Marlins Brewhouse before. The original one in south Fort Myers and this new, 2-month-old one in Estero’s University Village south of FGCU. I’d eaten at the adjoining Caliburger. I’d snacked on massive, salt-strewn pretzels with pints of Palm City San Carlos Proper, watching the cars go by on Ben Hill Griffin Parkway. 

But a fusion take on ramen, served table-side, that looked as stunningly good as this one?

I repeat: What the how?!

More: 40 years of JLB: How I learned to be a restaurant critic

More: Veg out: 63+ vegan and plant-based restaurants from Fort Myers to Naples

It wasn’t just a pretty bowl of soup. It was a masterful one: the noodles lithe and springy, the sunny egg and soulful broth, the complex spice of the collards, the chashu pork with its tantalizingly wobbly chew. 

Two bites in, I grabbed the Marlins menu and pored over it with forensic precision. Dishes I’d overlooked before jumped out now, one after the next: a cauliflower Caesar salad with tapenade and Parmesan crisps; a hot pot loaded with diver scallops, Gulf shrimp and Antarctic salmon in buttered dashi; thick-cut, fried-to-order potato chips dusted in house barbecue seasoning. 

Marlins’ Wild Fried Shrimp Platter ($17) includes fried Gulf shrimp and pickles, a loaded twice-baked potato, braised collards and a duet of dipping sauces.
Special to The News-Press

I’d been going about this taproom all wrong. Marlins Brewhouse might be the most interesting new restaurant in Estero. 

And all the credit goes to executive chef Noel Willhite (with a nod to Marlins’ owners Tim Frederic and Jeff Burns, who had the smarts to hire him). 

Willhite got his start locally as the garde manger at the Hyatt Regency Coconut Point. His resume includes stints at the former Spago in Chicago and Las Vegas’s Tao — which explains his love for ramen and hot pot, and his knack for the tomato sauces that underlie some of Marlins other great dishes. 

Like its bistro steak frites. 

More: CaliBurger opens at University Village with robots flipping, frying

Willhite takes a 10-ounce hangar steak, sears it till juicy, then teams it with charred cauliflower florets and thinly shaved pommes frites atop a tomato-cream sauce deepened by a touch of sherry. It is steak frites as I’ve never known steak frites. And yet, I loved it. Almost as much as I loved Willhite’s blue-cheese laced Buffalo chicken dip, his pimiento-cheese pretzel bones, his behemoth tray of beer-battered Gulf shrimp and pickles.

The bistro steak frites ($22) from Marlins includes a 10-ounce hangar steak, charred florets of cauliflower, and thinly shaved pommes frites atop a sherry-tomato cream sauce.
Special to The News-Press

This Deep South mashup was brilliant: the curls of shrimp, pink and briny-sweet; the pickles, tangy, bright, almost palate-cleansing. There were more collards, still spicy, still tender. Plus a twice-baked potato and two cups of house-crafted dipping sauces. It was an actual smorgasbord. All for $17. 

The true genius of Willhite’s Marlins work is its accessibility. It is, in essence, elevated beer food sold at beer-friendly prices. It’s food that tastes good with fruity daiquiris and honey-tinged hefeweizens. It’s food that begs to be shared. 

It’s food that’s fun.

Even when the server spilled a quarter of my beer across the table, giggled, then walked off one night. Even when I was left waiting (and. waiting.) for the check another. 

The fun of this menu overrides things like that. And really, how often do I get to call a place fun? Fancy restaurants are a dime a dozen, as are tasty dishes and classically trained chefs. But fun — as in taproom-french-pressed-chicken-wing-ramen fun — is rare.

Unless you’re at Marlins Brewhouse. 

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MORE: I am proud to be Jean Le Boeuf (I just can’t tell you who I am)

Jean Le Boeuf is the pseudonym used by a local food lover who dines at restaurants anonymously and without warning, with meals paid for by The News-Press and Naples Daily News. Follow the critic at facebook.com/jeanleboeufswfl or @JeanLeBoeuf on Twitter and Instagram.

More from JLB

Marlins Brewhouse Estero

University Village, 19800 Village Center Drive No. 235, Estero

JLB’s stars AREN’T like Yelp stars, here’s why… 

• Call: 239-790-6573

• Web: facebook.com/marlinsbrewuniversityvillage

• Hours: 11 a.m.-midnight Sunday to Tuesday, 11 a.m.-12:30 a.m. Wednesday, 11 a.m.-2 a.m. Thursday to Saturday

• Noise level: Conversationally loud to just plain loud

• Etc.: Full bar, outdoor seating, live music on weekends

• Everything pretzel, $11

• Pineapple-salmon lettuce wraps, $12

• Lobster shrimp mac, $15

• Bistro steak frites, $22

What the symbols mean

★ – Fair

$ – Average entree is under $10

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EXTRA: How single mum married her rug in bizarre wedding ceremony – TheCable Lifestyle

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Bekki Cocks, a 26-year-old casino worker, took a bold, albeit strange step in December 2019, when she tied the knot with ‘Mat’, an inanimate object — which turns out to be her “favourite rug.”

, the single mother of two’s marriage to ‘Mat’ follows her growing bond for the rug ever since she purchased it.

Bekki was then encouraged by her friends to marry the rug after she had on “several occasions” told them how “obsessed” she was with ‘Mat’.

“I bought Mat about a year ago and I’ve been banging on about how much I love him to anyone who will listen ever since,” she was quoted as saying.

“It became a bit of a thing with my friends who used to joke ‘if you love Mat so much why don’t you marry him?’. I spend so much time looking after him – cleaning him and vacuuming him a couple of times every day and making sure he always looks his very best – I couldn’t imagine being without him now.

“I am a little obsessed with Mat. When the kids are in bed, I’ll often just lie down with him and tell him my most private thoughts.

“I’m a single mum, so he’s become a confidant and I always seem to be able to think things through properly when we’ve been together. So, a few months ago when one of my friends said I should marry him, I said ‘I will then’.

“It started as a bit of fun but I soon started looking into a service and eventually it became something I was determined to go through with. I couldn’t be happier – I’m really looking forward to spending Christmas with Mat. I’ve also promised that while I might step on Mat from time to time, I won’t ever walk all over him.”

Single mum marries her rug! pic.twitter.com/gjvtQtJ5HT

— The Sun (@TheSun) December 7, 2019

Bekki, who was clad in a traditional all-white wedding dress during the intimate hour-long service, promised to love, honor and care for ‘Mat’ “till death us do part”.

The bizarre wedding ceremony took place at the Independent Fitters carpet store, close to Bekki’s home in Stockport in front of specially invited guests.

“We’re gathered here today in a special place to celebrate a very momentous day for Becky and her husband to be Mat. The love this two have for one another is rare and unique, and clearly, they have been swept off their feet since they met. Take this ring, wear it always and know that I rug you,” said the officiating priest.

“Mat we assume by your silence that you also feel the same. May every joy and happiness be yours, may your love wax stronger. I know present mr and mrs AD 20 Wool Twist. You may now hug the rug.”

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Buhari reacts to death of Abubakar – Daily Post Nigeria

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President Muhammadu Buhari has paid tribute to Alhaji Mohammed Abubakar Wabili, Sarkin Malamai, Gombe who died on Friday.

He described him as a man of impeccable integrity who unshakably stood by him before and after his foray into politics.

Wabili was Attorney-General and Commissioner of Justice when the President, then an Army Colonel, served as the Military Governor of the defunct Northeastern State, now made up of six states.

Speaking through a delegation he sent to Gombe, led by the Chief of Staff, Abba Kyari, President Buhari said it was rare these days to find men like the deceased who stubbornly held onto principles, standing for what they believed in, come rain or shine.

He recalled that from the moment he made up his mind to join partisan politics, the late Sarkin Malamai was part of a small group who sat down with him to draw his vision and programme of action to the voting public during the three times he ran for the presidency, until the fourth when he was elected.

‘‘He was in politics, not to make gains or hold positions but to see to the actualization of the vision for a greater Nigeria that we commonly shared. I remain appreciative of the intellectual and other forms of contributions he made to me since we started. May his soul Rest In Peace,” the President said.

At Government House Gombe the delegation was received by Governor Mohammed Inuwa Yahaya.

The Presidential delegation condoled with the government and people of Gombe State over the loss of the senior citizen and active elder of the All Progressives Congress (APC) who was committed to the party’s ideal until his demise.

Governor Yahaya of Gombe State thanked the President for sending a delegation to commiserate with the people of Gombe over the passing of Wabili.

“Your visit has given us succor. He lived a good life and lived for long.

‘‘He was an inspiration to Gombe State, the Northern geopolitical region and the Nation as a whole. He remained steadfast in support of Mr. President and we appreciate all he had been able to accomplish,” the governor said.

He assured the President that Gombe will continue to support the good policies of his administration to improve the welfare of Nigerians.

At the residence of the deceased, Sarkin Malamai, the family spokesman Alhaji Jibril Dukku also thanked the President for sharing in their grief.

The Minister of Communications and Digital Economy, Dr. Isa Ibrahim Ali Pantami, the Senior Special Assistants to the President, Ya’u Darazo and Garba Shehu, the Permanent Secretary, State House, Jalal Arabi and the Dan Madami of Daura, Musa Haro were on the delegation.

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Boyfriend chokes girlfriend to death in unique sex style

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The defence in the trial of a man accused of murdering British backpacker Grace Millane has begun its case in New Zealand.

According to The Telegraph, the defendant, a 27-year-old New Zealander who cannot be named for legal reasons, claims Grace died accidentally during sex at the end of a Tinder date in December last year.

Today the court was told that British backpacker Grace belonged to BDSM dating sites and allowed a former partner to choke her during sex.

An ex-boyfriend of the university graduate from Essex said they had used a system of safe words and signals to make sure she was never in danger.

In a statement read to the jury at Auckland High Court the man, whose identity is protected, said: ‘When we researched it we knew the word was asphyxiation. Grace and I discussed keeping hands wide and on the side of the neck, never on the front.

‘Grace and I would have a safe word most of the time which we had discussed, something like “turtle” or something ridiculous.

‘Grace and I used a tapping practice too. If Grace tapped me three times then it would stop.

‘Grace would tap out maybe one in four times. Grace would be sure to do this and I trusted that anytime it was too much for Grace she would do this.

‘Grace and I were careful to discuss not only the physical but the psychological aspects to practising BDSM.’ Statements from police revealed that Grace had been active on BDSM dating site Whiplr an hour before meeting the defendant outside a central city casino.

Defence barrister Ron Mansfield told the jury: ‘All the evidence shows that Miss Millane was a loving, bright, intelligent young woman and she was.

‘That is her reputation and that should be her reputation and her memory at the start of this trial and at the conclusion if it.

‘The fact that we need to discuss with you what she liked to do in the bedroom should have no impact on he reputation at all.’

He added: ‘It’s important that we are fully informed. It’s not the time for embarrassment or immaturity.

‘If this couple engaged in consensual sexual activity which included pressure being applied to her neck with her consent and that went wrong, that is not murder.

‘Death through this mechanism may thankfully be rare but it does happen and sadly it happened here.’ Grace died at the defendant’s apartment in Auckland last December.

Mr Mansfield said he admits Grace died from pressure he placed on her neck but said expert evidence was consistent with his account that it was consensual, not violent.

In his police interview, played at the trial last week, the defendant said he only realised Grace was dead when he found her lying on the floor.

He admits he later crammed her body into a suitcase which he buried in a shallow grave in nearby woodland. Grace Millane’s alleged murderer’s first interview with police.

Mr Mansfield claimed the defendant’s failure to call for help, disposal of Grace’s body and initial lies to police were due to ‘panic’.

He told the jury: ‘He may have thought he wouldn’t be believed, but don’t prove him right.’

The court has also heard evidence from pathologist Dr Fintan Garavan, appearing for the defence, who told the jury that due to the volume of alcohol Grace had drunk during the date, her heart may have gone into a ‘terminal tailspin’ when she was choked.

He told the jury a combination of obstruction of the blood flow, pressure on her nervous system and being drunk meant she might have died quickly.

He said there were no signs of her having struggled and that it ‘would not be obvious to a person nearby unless you know what you are looking for’ that she was in any danger.

A second defence barrister, Ian Brookie, told the court Grace had drunk six cocktails and a tequila shot and had shared three half-litre jugs of margaritas and sangria with her alleged killer while on their date.

Dr Garavan said: ‘It very likely has become an important indirect player in causing death’, explaining that being drunk could turn off a ‘safety valve’ which would normally trigger someone to fight for breath. He agreed the primary cause of death was asphyxiation, which he said would have required just one kilogram of pressure.

But under cross-examination, Dr Garavan agreed that once someone had become unresponsive during choking, the hold on their neck would have to continue for several minutes before death occurred. He added: ‘You would expect a sober person would notice something but not necessarily a drunk person.’ The trial continues.

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The Emperor’s new clothes: the politics of birth research — Sheena Byrom

In Hans Christian Andersen’s tale of the Emperor’s new clothes no one dares to say they don’t see a suit of clothes on him for fear they will be seen as stupid and incompetent. It takes the cry from a small child, “but he isn’t wearing anything at all”, to identifying the farce being carried out.

Sometimes research papers are put out with misleading media releases and political agendas that go unquestioned by a media hungry for controversy and the next sensational headline. In this blog we will identify the naked Emperor in the form of the recent New Zealand paper (NZ) published by (2016), titled A Comparison of Midwife-Led and Medical-Led Models of Care and Their Relationship to Adverse Fetal and Neonatal Outcomes: A Retrospective Cohort Study in New Zealand.  The Wernham paper caused consternation around the globe with doctors waving it in triumph pretending the Emperor had a magnificent outfit on while midwives scrambled to understand what was happening, crying amidst the crowd, “but he isn’t wearing anything at all.”  

How did something that was fairly low level scientific evidence get more attention, and lead to such public questioning of the safety of midwifery care, than 15 randomised controlled trials and a (CSR) on this issue?

Just a reminder about the Level 1 evidence of continuity of midwifery from over 17,000 women randomised in 15 separate RCTs:

“This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care. Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity models of care.”

 How did we ever think the Emperor had new clothes?

The first alert in this recent saga is the media release that came out from the first author’s university, strictly embargoed beforehand to excite the ‘crowd’ awaiting the emperors arrival. The media release revealed the first bias in the authors’ agenda and was the ultimate hook for the media:

“Mothers using autonomously practising midwives throughout their pregnancy and childbirth are more likely to have adverse outcomes for their newborns than those who use obstetricians, according to a retrospective study of nearly a quarter million babies born in New Zealand published in PLOS Medicine by Ellie Wernham of University of Otago, New Zealand, and colleagues.”

Firstly, this study was never about midwifery care during childbirth, or pregnancy for that matter. Midwives also look after women cared for by private obstetricians so this care is never just about medical care just as it is never just about midwifery care. Secondly, there was no statistical difference in perinatal mortality. You would have hardly known this from the media reports. Thirdly, the authors were clearly data dredging when they combined Intrauterine hypoxia, birth related asphyxia and neonatal encephalopathy in order to get a highly significant outcome. Rare adverse events and small numbers were sensationalised in the media release (“55 percent lower odds of birth related asphyxia, 39 percent lower odds of neonatal encephalopathy, and 48 percent lower odds of a low Apgar score at five minute after delivery”). Neonatal encephalopathy occurs 1-2 in 1000 births and is a rare event. Presented this way makes it sound so dramatic and it takes only one or two cases to change the outcome.

Why the Emperor is actually naked

The authors were unable to look at actual care during childbirth because they don’t appear to have this data, so they took model of care at booking and then misled the media and public that this was an indication of care at birth, when it was not. The problem with this is while all women who book with private obstetricians will remain under the care of private obstetricians from booking to birth, between 30-35% of women under midwifery care will be referred during pregnancy to a doctor. Despite this fact all outcomes (only adverse perinatal ones) in the paper are reported as due to midwifery care, when they are clearly not.

One could argue that the randomised controlled trials (RCTs) of continuity of midwifery care reported in the use a similar method – that is model of care on booking and intention to treat analysis. However, the difference is randomisation reduces selection bias and the study groups should be as similar as possible at the outset so the researchers can isolate and quantify the effect of the intervention they are studying (in this case midwife or medical care). In a RCT you can see what care women got and you would also know the mode of birth and maternal outcomes, which are not reported in this study. RCT’s can be used to change practice but lower level evidence should not; yet that has not stopped groups such as the calling for this in Australia.

The NZ study had several concerning limitations that were not adequately considered in the unfolding debate:

1.     One of the most significant findings of the CSR of continuity of midwifery care was the 24% reduction in preterm birth under midwifery care. There was also a significant reduction in perinatal mortality. Only women over 37 weeks were included in the recent NZ study, so there was no chance to see whether this important effect was seen in this study.

2.     Not only are of long term outcomes but there were a large number of missing Apgar scores and this was greater for women who booked with obstetricians.

3.     The inclusion of women more than 42 weeks, which were seen in larger numbers in the midwife booked group and are more likely to have stillbirths associated with prolonged pregnancies, is concerning. If the authors took 37 weeks gestation as a cut-off to exclude preterm birth (higher risk), why not take 41+6 to exclude the higher risk post-term pregnancies. It would have been very interesting to know how many adverse events were seen in the post-term group. Women choosing midwifery care are more likely to not want to be induced and to go over 42 weeks, as is seen in this study.

4.     The inability to separate antepartum stillbirth from intrapartum stillbirth is critical in trying to assess the impact of birth provider on outcomes and this could not be done, despite the study protocol suggesting it would be.

5.     In the study protocol published with the paper neonatal nursery admissions were examined but not reported. When we look at the author’s Master’s thesis where this information is available, more neonatal admissions are reported for babies born to women who booked with private obstetricians. This was not reported in this paper. One has to ask, why?

6.     In the first author’s Master’s thesis (where this study originally came from), substantially lower rates of caesarean section (22% vs 32.9%) and instrumental birth rates (9% vs 12.3%) are reported for women who booked with midwives, leading to significantly less maternal morbidity. Again this was not reported, giving a very one-sided view considering the authors are virtually questioning the entire NZ maternity system.

7.     There appears to be quite a bit of missing data in this study and it is unclear how this was dealt with in the analysis.

8.     Many socio demographic variables are not accounted for (e.g. alcohol and drug use), and others such as smoking are notoriously underreported. Midwives tend to look after women with greater socio demographic disadvantage and mental health issues. None of this is adjusted for.

9.     Other medical complications that arise following booking, such as gestational diabetes, pre-eclampsia, etc are not accounted for and may be increased in women who book with midwives due to ethnicity factors, life style etc.

10.  Rurality and birth place were not taken into consideration, limiting the usefulness of this study to help make targeted changes rather than slamming the entire N Z maternity system.

11.  There is no difference in PMR between Australia and NZ despite the fact that 30% of care in Australia is by private obstetricians whilst in NZ around 90% of women have a midwife as a lead care provider.

12.  A previous NZ paper that also hit the media headlines in recent times, purporting to show the risk of perinatal death was higher when midwives were in their first year following graduation, has recently been questioned by the who have been unable to replicate the study. This is worrying.

13.  of low risk women in NSW who had a birth in a private hospital under private obstetric care with low risk women who had a birth in a public hospital with midwife/medical care we found greater morbidity for women giving birth in a private obstetric model of care.

The one highlight in this whole saga has been the united support of the midwives in NZ by the , The , , and bodies around the world.

The political fallout from this paper has been extraordinary, for it actually tells us very little. No practice changes could ever be made based on this study. The Emperor may have no clothes, but the delusion has been maintained by a misleading media release, politically motivated reporting of findings by the authors, a hungry unquestioning media sensing blood in the water and wanting sensational headlines, and obstetricians determined to drag the advances made by the profession of midwifery back to the ‘good old days’ when they were compliant handmaidens. 

#ENOUGH

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Doctors of Death: Nigeria’s medical misdiagnosis crisis | P.M. News

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*A Special Report by P.M.NEWS

Doctors at work in Idah General Hospital, Kogi state: Misdiagnosis of ailments now a major crisis in Nigeria

By Lanre Babalola

His patient lost a kidney and died but Dr Yakubu Koji was unwilling to admit responsibility when he faced in September a tribunal set up by the Nigerian Medical and Dental Council to try a tribe of reckless and professionally negligent doctors in the country.

According to the tribunal documents, Koji of the Jimeta Clinic and Maternity, Adamawa was charged with gross professional negligence which led to the death of a patient in his care.

He was accused of incompetence in the assessment of the patient and incorrect diagnosis of his illness. To worsen matters, Koji operated on the patient because the patient insisted he should do the operation.

At the tribunal, Koji was told he was negligent in advising the patient on the risk involved in the operation, and also failing to obtain an informed consent of the patient.

At the same tribunal in September, Dr Ikeji Charles of Kefland Family Hospital, Apo Mechanic Extension, Abuja,was arraigned for causing the death of his patient, after surgery for hernia.

Charles was charged with four counts of incompetence and negligence. But like Koji, he also pleaded not guilty.

Regularly, the medical council tribunal holds sessions to hold Nigerian doctors to account and at the end, it suspends doctors found guilty of professional negligence for some months or in rare cases, ban them from practising. The session in September was the third this year.

Minister of Health Osagie Ehanire

One of the doctors recently convicted by the tribunal was Kebbi-based Jamilu Muhammad who erroneously diagnosed that a baby in the womb was dead and then carried out surgery to evacuate the supposedly dead baby. The operation however showed that the baby was alive, but the doctor had amputated the baby’s upper limb as he dissected the mother.

The medical council revealed recently it was investigating 120 doctors for various professional misconduct, while 60 others were awaiting trial at the Tribunal.

Chairman of the medical tribunal, Professor Abba Hassan, right with former health minister, Professor Adewole

Although the tribunal often sanctions the errant doctors, it is debatable if the sanctions were fitting enough for the death of their patients and the anguish this triggers for their families.

Many Nigerians have had unpalatable experiences in the hands of doctors who misdiagnosed their ailments and went on to prescribe the wrong drugs and the wrong treatment. Not many of these patients lived to tell their stories.

Across the country some Nigerians of all classes are dying of common ailments due to wrong diagnosis and drug prescriptions by supposedly trained Nigerian medical doctors.

Wrong diagnosis has become a major and lingering crisis afflicting Nigeria’s medical sector. No wonder, those who could afford it, including the nation’s president and the political leaders, whenever they fall ill, dust their passports and head to Europe, America, Middle East and Asia to seek help.

May be Nigeria would still have had human rights advocate, Chief Gani Fawehinmi alive today, if his lung cancer was detected early. But a Nigerian doctor who examined him said he was suffering from asthma and plied him with plenty asthma drugs. Fawehinmi lamented in the latter part of his life that if his ailment had been correctly diagnosed earlier, he would have taken proper care of himself. He died in 2009.

Gani Fawehinmi: lung cancer diagnosed as asthma

Afrobeat star, Femi Kuti recently tweeted about his late younger sister, Sola, who died due to wrong diagnosis by Nigerian doctors.

Wrong diagnosis has always been a problem in our country.

In 1985, Abudu Razaq, a young student of The Polytechnic, Ibadan complained of severe pains in the lower abdomen and was rushed to the State House Clinic in Marina, Lagos Island. After examining him, the doctors referred him to the then newly founded St. Nicholas Hospital, near City Hall. The team of doctors examined him and concluded that he was suffering from what they called Appendicectomy and an operation to cut the appendix was recommended. They opened him up and later realised that the appendix was not ripe enough to be cut. They removed the stones in the appendix and sealed him up— a classic case of misdiagnosis by supposedly well-trained doctors. What if the patient had died in the course of the ill-advised operation based on the wrong diagnosis?

Another case of misdiagnosis by Nigerian doctors is that of Ade Bisiriyu(not real name) a patient with a sleeping disorder who walked into a clinic at Ikeja, Lagos and complained to the doctor that he couldn’t sleep at night. He told the doctor he was urinating five, six times in the night. The doctor took his body temperature, samples of his blood and urine for examinations and gave him some injections (anti-biotic) which he took for five days.

The patient came back to complain that he still couldn’t sleep. The doctor now zeroed on the patient’s age, he was 56 and declared the patient must be having prostate issues. The doctor advised him to go for a scan at a diagnostic facility on Adeniyi Jones, Ikeja. After perusing at the scan result, he concluded that the patient was suffering from prostate enlargement and recommended some drugs.

But rather than abate, the ailment became worse with the patient observing blood in his stool and pains in the anus. He went back to the doctor and the doctor analysed that it has resulted in haemorrhoids caused by acute pile. He recommended drugs again but the drugs fail to provide succour to the patient.

The pains in the anus got so severe that the patient became so confused.

He went to the doctor again and the doctor recommended that he go for another prostate scan and what he called Colonoscopy.

”After this consultation and the doctor’s reaction to my complaint, I knew he has reached a dead end. He has no solution to my problem. He was only interested in the money. I had to seek a new medical advice,” said the distraught patient.

He sought help with a doctor in Ado Odo-Ota, Ogun State. The doctor at the private medical facility listened to the patient’s complaint, asked him to go for an abdomen scan. After studying the result of the scan, the patient was placed on drips in the hospital for a 24-hour observation. Some injections were given and drugs recommended. After weeks of taking the drugs, the pain did not abate. Rather, it got worse. The patient had emaciated considerably and it was visible he was suffering internally.

Dr. T. A. Sanusi, Registrar Medical and Dental Council

The patient went to complain again to the doctor. The doctor conducted further tests and concluded it was cancer of the anus. The patient is still battling with this ailment.

Bayo Onanuga: I nearly lost my leg

I nearly lost my leg

In 2006, journalist Bayo Onanuga had a freak accident at home. He fell off a ladder and fractured his ankle. It was a bad fracture, what orthopaedic doctors called ‘pilon fracture’. The right ankle bone was badly shattered.

‘It happened about 5.30 am, as I jumped down from a ladder, that I felt was giving way under me, while changing the bulb In my pantry. I was helped to the General Hospital at Ikeja by a colleague, immediately after.

“At the hospital, an x-ray was done, which confirmed that the ankle was badly broken. The doctor on duty was given the x-ray and then he proceeded to cast my foot in POP.

“I immediately complained about serious discomfort after the POP cast was done: I felt some burning sensation in the sole of my foot. What I felt was beyond pain. My leg was literally on fire.

“I told the doctor, what I was feeling. He said I should bear the pain and gave me analgesic.
I took the analgesic and yet the sensation did not subside.

Dr Jonathan Osamor: offers suggestions on helping doctors

“I was lucky, I was stretchered into a LASUTH VIP ward for observation after the casting. As I lay on bed, I kept complaining that my leg was ‘burning’. The nurses on duty could not understand why an adult that I was should be complaining like a baby. I persisted in ventilating my complaint.

“When it seemed they would not listen to me and they appeared not to empathise with me, I peeled off the POP. It was still wet and in minutes, I succeeded in removing it. I instantly felt relieved and I fell asleep, leg raised on a wooden plank.

Some hours after, an orthopaedic surgeon came to check on me. The first question he asked was: “Who put the POP on this man’s leg?” The nurses kept conspiratorially mute.

”And then the surgeon dropped the bomb: “If this POP had remained on this leg for five hours, the leg would have developed gangrene and we would have needed to cut it off.”

”The nurses were too ashamed to say anything. I was right and they were wrong. And the doctor who put the cast, without checking the x-ray was more criminally negligent.

“The surgeon said my ankle needed an operation and because the leg had swollen up, I would wait for one week for the operation to take place.

“I had no choice. I waited. Exactly a week after, the operation was done to deal with the pilon fracture that I had sustained.

“Though the operation was successful, with some metals put inside my leg to allow the broken bone regrow, it came with its own issues. The metals were not properly set. I ended up spending seven months at home, for an injury that should not have taken me off my routine for more than three months.

“In my case, after four months at home in Lagos, without appreciable healing, I had to travel to the UK for assistance. Three months after, I was back on my feet.

I nearly died of pneumonia

Onanuga also shared his experience with another doctor when he nearly died of pneumonia. His doctor diagnosed it as muscular pain.

“On a Saturday morning, one day in 2010, I drove myself to my doctor and told him I had pneumonia.

“He asked me about the symptoms I had. I said I felt breathless when I climbed the stairs. I could no longer exercise because of this. I said I felt some pain in my rib cage on the right and I was not feeling very well.

“He didn’t agree with me that my symptoms spelled pneumonia. Instead, he said what was ailing me was ‘muscular ache’.

“To resolve all arguments, he asked me to go for a scan. I did. The result however did not confirm my own diagnosis. The area of my body scanned showed nothing.

“My doctor said: “I told you so, you do not have pneumonia. You have muscular ache. So he gave me some analgesics.I took the medicine home and used as prescribed.

“By the evening of same day my diagnosis was confirmed by what I began to notice. In the night, I went downstairs in my house to pick something in the backyard and suddenly I was gripped by excruciating pain in my stomach. I crouched and had to maintain the position to crawl back into the house. I was the only one at home. My wife had travelled.

“The following day, I became more alarmed. When I sneezed, the mucus that came out was laced with blood. When I coughed, I also saw blood in my phlegm. These are signs of pneumonia that a senior colleague of mine had experienced. I decided to help myself and Googled the best medicine for pneumonia.

“I wrote it down and went to one of the best pharmacies in Ikeja to buy the drug. I started to use it instantly. Two days after, I decided to seek help, again in the UK.

“I was diagnosed with pneumonia. The scan done by a female Nigerian trained radiologist, now working in the UK, picked up some blood clots in my rib cage area. The doctor said the pneumonia would have killed me and even wondered how I had survived. I didn’t tell him I was on my own self-prescribed medication.

“He gave me the same drug that I bought in Lagos, with an additional one. And he asked me to start using them immediately. About five days after, the pneumonia was clear and I was fit enough to return to my country.

Another case of misdiagnosis by Nigerian doctors was narrated by a female journalist who blamed wrong diagnosis by doctors for her brother’s death.

”I lost my immediate elder brother to the cold hands of death on Saturday, February 25, 2017, due to what I call inconclusive diagnosis. Prior to his death, he was a known Sickle Cell Disease (SCD) patient, and he was well managed by my parents and other members of the family.

“He came over to my parents’ complaining of fever and leg pain, and on Thursday night, he became unconscious and was rushed to the hospital, unfortunately, he didn’t survive the experience. His blood sample was collected and a series of tests conducted on him.

“Initially, he was said to have suffered from stress, which was as a result of insomnia he experienced some weeks before he took ill.Then another result came in on Friday evening that he had a Stroke, and it had affected his brain.

“I didn’t understand what that meant, especially since he could move his limbs, but his eyes were open with him rolling his eyeballs involuntarily; he was neither here, nor there.

“Once the result about the brain stroke was handed to my mum, we were advised to take him for a Magnetic Resonance Imaging (MRI) – a brain scan, to ascertain the depth of the damage caused by the stroke to his brain. This was only done in 2 hospitals in Lagos.

“When his condition became really unstable Friday night and this caused my mum to shout and panic as she sought help for her son, one of the doctors carelessly said that she should not disturb them with her noise as he was going to die eventually.

“After a series of attacks and instability on Friday night with doctors battling to keep him alive, they managed to resuscitate him with oxygen, unfortunately, he passed on Saturday morning.

“He died before midday. Doctors claimed he died from jaundice complications and that confused me the more”, she said.

Fictional Aneurysm

Sumbo Adeyemi, a Nigerian lady in her twenties complained of severe headache all the time. She first went to St Nicholas Hospital in central Lagos, where the doctor she met, after a scan, diagnosed that she had Intracranial aneurysm and recommended a brain surgery for the supposed ailment.

Alarmed, her relations asked her to seek another diagnosis, from another doctor. The new doctor recommended an MRI scan at a Mecure centre in Lekki. The scan showed not aneurysm but another ailment in the brain.

Confused because of two conflicting diagnosis, Sumbo’s family suggested a third diagnosis outside the country.

In the UK, about 12 doctors, who attended to her rejected outright the two conflicting scans done in Lagos and said they could not have been for the lady.

They then told her that her problem was migraine and that it was caused by insufficient sleep and stress. They advised her to stop watching football, among other stressful things. She was then given some analgesics to use.

The lady is married now and has children and the “migraine” had disappeared. What if she had agreed that doctors open up her brain, in search of a non-existent aneuryism?

Certainly, something is wrong with Nigerian doctors such that they keep missing the goal post in diagnosing their patients’ ailments.

Dr Jonathan Osamor of the Oyo State General Hospital, Moniya, Ibadan gave some explanations: .

“For wrong diagnosis to be made, there are so many components. The first important component is clerking, taking down the history from the patient. If your patient cannot explain very well, you may not be able to extract relevant information from him or her. There could be communication barrier, which may occur as a result of the patient speaking one language and the doctor speak another. Your interpretation of the complaint goes a long way. You may misinterpret the complaint. Another component is you physically examining the patient, whether you can elicit any kind of sign from the patient. That is where your own clinical skill comes in. If you are not versed clinically, you may not be able to identify which of the system of the body is faulty.

“The body is divided into systems – cardiovascular for the circulation, chest for respiratory, abdomen and so on. So, if you examine the system and you are not able to elicit information on some signs that will point to where that pathology is, then you fall back on investigations. Investigation also depends on if the patient has the money and if the laboratory facility is adequate. In other words, there are so many components that could go wrong.

“But you see, it supposed to be a team work. The first point of contact is the junior doctor who has to review with his senior. That is the check, the control. But if you have a facility such as a primary healthcare centre or a local government hospital whereby the doctor is all in all, then there is bound to be a problem.

So, it is the fault of the system we are running. There is no funding, there is no policy from the policy makers as to the milestones you can achieve. The point is that when you have a system that is not organised, it becomes chaotic and things like wrong diagnosis and prescription can occur”, Osamor said.

“Take for instance, general hospitals where the staff are not enough. They may not be able to interpret the complaint of the patient accurately. That can lead to wrong diagnosis and of course, that will be predisposed to wrong prescription. So, it is a lot of components that are involved: Patient communication, presentation, the language barrier, your own understanding or level of your experience, how you were exposed and then laboratory interpretation. If the lab is not functioning, you may just prescribe without waiting for laboratory confirmation of the particular complaint the patient has.

“So, it is the fault of the system we are running. There is no funding, there is no policy from the policy makers as to the milestones you can achieve. The point is that when you have a system that is not organised, it becomes chaotic and things like wrong diagnosis and prescription can occur”, Osamor said.

Dr Sulaiman Abiodun, Obstetrician and Gynaecologist at University College Hospital, also in Ibadan largely agreed with Osamor. Abiodun also blamed poor training of medical doctors, work load and poor rewards as the reasons for rampant misdiagnosis.

“When doctors are overworked, there may be a problem. Everybody has a limit. The moment one has gotten to his or her limit, you cannot expect him or her to perform optimally compared to when he or she has not been over stretched. When you are over stretched, stress will surely set in. The system cannot have the best of you again. Also, many doctors do not have adequate sleep due to the enormous and overwhelming work they do. All these factors will affect the efficiency of the doctors or the quality of the services they will render.

Abiodun also identified poor and non-functioning equipment for diagnosis as part of the crisis of medicare in Nigeria.

How can we stem the crisis of misdiagnosis? Osamor again volunteered some suggestions:

“First for all, the policy makers must have a vision that will guarantee a standard practice in the medical industry. The policy making bodies like hospital management board and ministry of health must be determined to do things rightly. There must be political will to make things work.

“Funding is another issue. The government must fund healthcare system properly. A lot of hospitals don’t have adequate consulting rooms. The roof of a hospital is leaking. There is a structural decay. Also, staffing is very important. You must be able to staff and encourage your staff to the level that they are retained.

“So, there is need for manpower, human capacity building, in-service training, seminars, conferences that they should go so that they can be exposed. And of course, remuneration. Remuneration is very important. If the doctors are well remunerated, they will stay in Nigeria and give their best and there will not be issue of brain drain. So, we have a problem of systemic failure. Policy makers should be able to make a lot of difference when it comes to that”, Osamor said.

Like Osamor, Abiodun also stressed the need for training and retraining doctors. Training, he said, is very important to any profession. “To enable doctors receive good training in medical schools, government needs to properly fund medical institutions and adequately provide necessary equipment to train them with. After medical schools, training and retraining is important so that the doctors will not be outdated”.

*With reports by Gbenro Adesina/Ibadan; Olufumilola Olukomaiya & Jennifer Okundia.

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