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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anna Bertone:   Exactly.

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

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

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

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

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

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

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

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

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

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

They only had an 11% cesarean rate then?

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

…And what about for the babies then? – 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anna Bertone:   Correct. Yes.

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

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

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

Anna Bertone:   That’s my understanding. Correct.

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

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

So it’s quite a global sample.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Anna Bertone:   Yes. More worried.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Article 4 specifies that:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Looking Back Through a Misty Film: Recollection from the 2019 Purple Hibiscus Creative Writing Workshop

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by Bura-Bari Nwilo

In December 2019, I stood over Oly in my apartment in Nsukka and drew her attention to posts of Facebook friends who had screenshot acceptance letters signed by Chimamanda Ngozi Adichie for the year’s creative writing workshop. And in my eyes, she could see mild fury hinged on disappointment. I deafened her with tales of my yearly rejections and why I felt I had a right to be disappointed with all things Nigerian.

Then by whatever stroke of fate it was, I checked my email and saw my own letter. Like a letter I had once received explaining how I was among a shortlist of 50 amazing writers and the apology for what could not become my invitation letter, I read those years of rejection and apology into what was an acceptance letter for 2019. When I read through to the second paragraph, I felt an inch taller and almost swiftly, I was massively subdued, like I stood on a tower of resentment for all that had been my misfortune and it turned out it was a day of glory.

When I read through to the second paragraph, I felt an inch taller and almost swiftly, I was massively subdued, like I stood on a tower of resentment for all that had been my misfortune and it turned out it was a day of glory.

Oly shared kind words with me and I went back to the email to see if I had not been too optimistic to have read into a poor letter an acceptance that was only in my imaginations. And I was not dreaming. I was truly invited to the now renamed Purple Hibiscus Creative Writing Workshop after more than five rejections.

At the workshop, I shared experiences of my years of application and some of the wild thoughts I had nurtured. Once, I had thought that my serial rejection, after many of my friends were invited, was because I was not Igbo and I thought I could change my name to allow me entrance. Don’t die yet. And for the year I received a consolidation email signed by Ms. Adichie, I could not mix anger with such obviously patronizing letter. Goodwill messages from Facebook friends, of how I was such an interesting writer, added in me some courage to keep writing. And looking back at such thoughts, I am grateful it ended up between Arinze and me.

And for the big question in class, I asked Ms. Adichie what interested her in my entry that did not meet her many years ago, especially since it was just a regular story, something I had not even taken seriously, against the many I had written with all hopes and concern. And there, I concluded that maybe what makes the big mark comes in the funniest wrap. I had written a story about a serial killer who lured her victims, especially taxi drivers. The killer writes about the incidents on her blog. The few paragraphs I sent were the reason I was invited.

And there, I concluded that maybe what makes the big mark comes in the funniest wrap.

I come from a place of ‘serious’ literature. And I have tried creating most of that seriousness. I have given elbowroom to experimentation and maybe it is why I am yet to decide on writing a novel. And after listening to other participants share their acceptance tales; I knew that I was not alone. We were a universe of people motivated by Chimamanda and would do as much as applying for several years just to hear her up-close, watch her read and share thoughts on story writing and being a writer while addressing us by our names and whatever it was that made us stand out.

The 2019 workshop had it a bit unfortunate. The classes were cut to five days instead of ten days and a lot of things had to be stuffed into a really tiny car. Chimamanda, Lola Shoneyin, Eghosa Imasuen, and Novuyo Tsuma Rosa gave us thrilling experiences with backbreaking tasks: reading multiple stories into late night and class writing tasks that would see you read aloud your writings and listen to others and give constructive feedback. We made a coolly glossy family in a few days than would have been imagined. And maybe the shared rooms enabled bonding, but the 2019 workshop was tense, practical, overwhelming, indulging, compelling and it ended on such evenings where writers knew tears like they knew words and sentences. And those whose tears did not make the warm walk through cheeks, it formed a bubble in their hearts and stayed there as a priceless memory.

Her brilliance lies more in her ability to share quite controversial yet informed thoughts without breaking anyone’s back.

Chimamanda Ngozi Adichie is brilliant and adorable in giving kind words. We share a birth date with a ten-year age difference and that’s my consolidation for being a lazy writer. Her brilliance lies more in her ability to share quite controversial yet informed thoughts without breaking anyone’s back. Her playfulness and humane jibes and photo sessions informed me that it takes more than a fine head and great skill to be a superstar. A sprinkle of warmth, friendliness and sometimes vanity could be other awesome additions.

With the workshop, Chimamanda builds confidence, encourages collaboration, and invents homes for broken yet agile storytellers whose shortcomings are not only placed outside the spotlight, but their strength and wellness are given so much cheers and support to germinate.

Bura-Bari Nwilo is the author of The Colour of a Thing Believed, a book of short stories.

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World’s oldest couple set to celebrate 80th wedding anniversary

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John Henderson, aged 106 and Charlotte Curtis aged 105 are officially recognized by the Guiness Book of World Records as the world’s oldest couple and will on December 22, 2019, celebrate their 80th wedding anniversary, and 85 years after sitting in a zoology class in 1934.

John and Charlotte married in a tiny ceremony with only two guests present on Dec. 22, 1939 and during their honeymoon in San Antonio, they stayed at a hotel that cost $7 a night.

Even though they known each other for 85 years, they have been married only for 80, meaning the record for the longest marriage according to Guinness World Records, belongs to Zelmyra and Herbert Fisher, who wed at the ages of 17 and 19, respectively, and were married for 86 years and 290 days before Herbert’s death in 2011.

Speaking to Washington post on Sunday, John Henderson said;

“it took her five years to make up her mind that she wanted to get married,”

Speaking about the first time he got a radio, John said;

“And I well-remember that long antenna. They had to put it up from the front yard to the backyard to receive a radio show,” he said.

He recalls renting a room while in the University of Texas in the early 1930s across the street from the Gregory Gym, one of the few historical buildings remaining on the campus.

“The neighbors next door had a cow and chickens. You can imagine today a cow and chicken house across the street from Gregory, where the campus is so large now you wouldn’t recognize hardly anything,” John said.

“I thought he was just a fine fella, and I didn’t mind his looking over my shoulder,” Charlotte told The Washington Post, remembering the first time she saw John in a Zoology class in front of John while he made passes at her.

The pair have been lauded by many for their long, milestone-filled life together.

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“If You Broadcast A Child You Might Lose The Child”- Yinka Ayefele Reveal Why He Denied The Birth Of His Triplets

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Top gospel singer, Yinka Ayefele has revealed the reasons he denied the news of the birth of his triplets.

In a recent interview with TONTRENDS, Ayefele stated, “Yes, I even denied it once when it happened. When the news broke a lot of people were talking about it because my babies were very tiny because they were born prematurely’.

“So, I was afraid to broadcast. I did not want to lose them after the long wait and according to a Yoruba adage that says if you broadcast a child you might lose the child, so, I decided to keep it within the family until they are fully grown and healthy.

“That is why I denied it when the news got out. But my partner told me not to be afraid, that God, who gave the kids will surely protect them and that was when I came out to tell people. I was initially afraid of how they looked, very tiny, thank God today they are big.

“It was hard to keep it a secret. A lot of colleagues in the media knew about it but I told them to hold on till the right time to broadcast it. I tried as much as I could to keep the news from getting out, I did not release any of their pictures,” he said.

He further revealed that the triplets; two boys and a girl were born on January 18, 2019 at Holy Cross Hospital in the USA. He also explained how it felt like, from the moment his wife was confirmed pregnant till the time the babies arrived.

“It was stage by stage. Are you asking me when we first went for the pregnancy test or when the pregnancy was a month, 3 months, 6 months or 9 months, or during labour or the day my wife gave birth? I can’t explain it each month from the 8th day she was confirmed pregnant. I most ran mad when I heard she was pregnant.

“I could not believe it after series of attempts. I didn’t know who to explained it to, but the night she gave birth it was as if I have seen them together before because I have followed her to many scan sessions. It was like welcoming them fully that night. I can’t really tell how I felt that night,” he said.

The singer also spoke about the joy he felt, when his wife got pregnant and how grateful he was to God as many had thought he could never have a child after 22 years of marriage.

“I don’t mind having triplets, even if I can go as far as having 20, I really don’t mind because the pain of looking for a child was so aggravating. It wasn’t easy going to mountains for prayers, going to different hospitals, both at home and abroad, doing one test to the other.

“Yinka Ayefele is on a wheelchair, people think I can’t get a woman pregnant because of my situation, because of my spinal cord issue. Eventually, God blessed me with triplets,” he added.

The post “If You Broadcast A Child You Might Lose The Child”- Yinka Ayefele Reveal Why He Denied The Birth Of His Triplets appeared first on Talk of Naija.

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Yinka Ayefele Opens Up On The Birth Of His Miracle Triplets & Why He Kept The News From The Public – Motherhood In-Style Magazine

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Nigerian veteran music star, Yinka Ayefele has opened up on the birth of his babies and why he kept the news of the birth of the triplets Richard, Eniola and Raymond, from the public.

According to the Juju singer, he feared for the lives of his new triplets – two boys and a girl – who were prematurely born on January 18.

In June, the news of the birth of the miracle triplets was broken by some trigger happy media platforms but the singer vehemently denied it, saying it wasn’t true. In a new interview with , Ayefele said he denied the reports because they were on intensive care. He shared:

”Yes, I even denied it once when it happened. When the news broke a lot of people were talking about it because my babies were very tiny because they were born prematurely’.

So, I was afraid to broadcast. I did not want to lose them after the long wait and according to a Yoruba adage that says if you broadcast a child you might lose the child, so, I decided to keep it within the family until they are fully grown and healthy.

That is why I denied it when the news got out. But my partner told me not to be afraid, that God, who gave the kids will surely protect them and that was when I came out to tell people. I was initially afraid of how they looked, very tiny, thank God today they are big.

It was hard to keep it a secret. A lot of colleagues in the media knew about it but I told them to hold on till the right time to broadcast it. I tried as much as I could to keep the news from getting out, I did not release any of their pictures.”

For over 20 years, the famous Tungba exponent battled a fertility challenge following a ghastly accident that has since confined him into a wheel chair after a spinal cord injury. With the belief by many that it cannot happen again, Ayefele never wavered as he believed in the spiritual power of God as well as modern science.

Speaking further, the dad-of-three confirmed that the triplets; two boys and a girl were born on January 18, 2019 at Holy Cross Hospital in the USA. He also explained how it felt like, from the moment his wife was confirmed pregnant till the time the babies arrived. In his words:

“It was stage by stage. Are you asking me when we first went for the pregnancy test or when the pregnancy was a month, 3 months, 6 months or 9 months, or during labour or the day my wife gave birth? I can’t explain it each month from the 8th day she was confirmed pregnant. I most ran mad when I heard she was pregnant.

I could not believe it after series of attempts. I didn’t know who to explained it to, but the night she gave birth it was as if I have seen them together before because I have followed her to many scan sessions. It was like welcoming them fully that night. I can’t really tell how I felt that night.”

In addition, he said he could not believe his eyes when his wife got pregnant and was full of gratitude to God when the triplets were born as many had thought he could never have a child after 22 years of marriage.

“I don’t mind having triplets, even if I can go as far as having 20, I really don’t mind because the pain of looking for a child was so aggravating. It wasn’t easy going to mountains for prayers, going to different hospitals, both at home and abroad, doing one test to the other.

Yinka Ayefele is on a wheelchair, people think I can’t get a woman pregnant because of my situation, because of my spinal cord issue. Eventually, God blessed me with triplets.”

The 51-year-old also said that his triplets tend to eat, cry, and defecate at the same time, adding that the most difficult part of it all is having to carry all of them at a time.

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2020 presidential race could weigh on FANG stocks

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The 2020 presidential race could weigh on ‘FANG’ stocks as Democrats attack big tech

As 2020 presidential campaigns accelerate, the dominance of Silicon Valley technology companies is likely to remain a key issue for Democratic candidates, Bank of America analyst Justin Post said in a note to investors on Monday.

“Campaign focus on FANG regulation [is] likely here to stay,” Post said.

Sen. Elizabeth Warren last week unveiled a plan to break up the biggest tech companies if she is elected president. The Massachusetts Democrat is especially focused on four of Wall Street’s beloved “FAANG” stocks: Facebook, Amazon, Apple and Google-parent Alphabet. The group also includes Netflix.

“The giant tech companies right now are eating up little, tiny businesses, start-ups – and competing unfairly,” Warren told CBS on Sunday.

“We’ve got to break these guys apart,” Warren added. “It’s like in baseball: You can be the umpire or you can own one of the teams, but you don’t get to be the umpire and own the teams.”

Post analyzed the “breakup scenarios” for Alphabet, Amazon and Facebook, which Warren referred to repeatedly in her criticism. While forced spinoffs may largely help the former two tech giants, Post thinks Facebook is the most at risk to seriously losing shareholder value.

Bank of America sees “a partial breakup of Alphabet (including spin of YouTube or Waymo)” as possibly “value enhancing.” With the broad reach of each of Alphabet’s business units, as separate entities, each brand “has enough scale to capture vast advertiser interest,” Post added.

Similarly for Amazon, Post said a breakup “would be somewhat neutral for the stock,” as investors in Jeff Bezos’ empire “are generally comfortable” with how much Amazon’s businesses would be worth on their own.

Breaking up Facebook “could be most concerning for investors,” Post said. He found that if Facebook’s Instagram and WhatsApp platforms were separated, they “would likely compete directly with Facebook for usage and advertisers, raising concerns on increased competition.”

That overlap in Facebook’s businesses is a key reason Warren believes they should be separated.

“They bought the competition and now they’re sucking the data out of the competition,” Warren said.

While Bank of America did not include Apple in its breakup analysis, Warren confirmed to CNBC that she intends to break up the iPhone maker. In her interview with CBS, Warren argued that she is not against markets, which she said “produce a lot of good,” but instead thinks “markets have to have rules.”

“It is not capitalism to have one giant that comes in and dominates, a monopolist that dominates a market,” Warren said.

Warren said recent talks with technology venture capital firms revealed that the places where Amazon, Facebook and Google compete are known as “kill zones” to entrepreneurs.

“They call it the kill zone because they don’t want to fund businesses in that space because they know Amazon will eat them up, Facebook will eat them up, Google will eat them up,” Warren said.

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‘Why I kept the birth of my triplets away from public’ – Yinka Ayefele

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Popular Nigerian gospel singer, has finally opened up on why he kept the news of the birth of his triplets from the public. At a point when the news was broken by some trigger happy media platforms, the singer vehemently denied it, saying it wasn’t true.

Although many have come to know of the truth but Ayefele officially made it public in an interview with Vanguard’s Potpourri.

“Yes, I even denied it once when it happened. When the news broke a lot of people were talking about it because my babies were very tiny because they were born prematurely. So, I was afraid to broadcast. I did not want to lose them after the long wait and according to a Yoruba adage that says if you broadcast a child you might lose the child, so, I decided to keep it within the family until they are fully grown and healthy.

“That is why I denied it when the news got out. But my partner told me not to be afraid, that God, who gave the kids will surely protect them and that was when I came out to tell people. I was initially afraid of how they looked, very tiny, thank God today they are big.

“It was hard to keep it a secret. A lot of colleagues in the media knew about it but I told them to hold on till the right time to broadcast it. I tried as much as I could to keep the news from getting out, I did not release any of their pictures,” he said.

He confirmed that the triplets; two boys and a girl were born on January 18, 2019 at Holy Cross Hospital in the USA. He also explained how it felt like, from the moment his wife was confirmed pregnant till the time the babies arrived.

“It was stage by stage. Are you asking me when we first went for the pregnancy test or when the pregnancy was a month, 3 months, 6 months or 9 months, or during labour or the day my wife gave birth? I can’t explain it each month from the 8th day she was confirmed pregnant. I most ran mad when I heard she was pregnant.

“I could not believe it after series of attempts. I didn’t know who to explained it to, but the night she gave birth it was as if I have seen them together before because I have followed her to many scan sessions. It was like welcoming them fully that night. I can’t really tell how I felt that night,” he said.

Speaking further, he said he could not believe his eyes when his wife got pregnant and was full of gratitude to God when the triplets were born as many had thought he could never have a child after 22 years of marriage.

“I don’t mind having triplets, even if I can go as far as having 20, I really don’t mind because the pain of looking for a child was so aggravating. It wasn’t easy going to mountains for prayers, going to different hospitals, both at home and abroad, doing one test to the other. Yinka Ayefele is on a wheelchair, people think I can’t get a woman pregnant because of my situation, because of my spinal cord issue. Eventually, God blessed me with triplets,” he said.

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‘Joker’ uses a song by convicted pedophile Gary Glitter. He’s probably making money off it

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(CNN)The controversy keeps building for Warner Bros.’ “Joker” movie.

The song, “Rock and Roll Part 2,” plays for about two minutes as star Joaquin Phoenix, who plays the Joker, dances down a flight of stairs.
Gary Glitter: 'Joker' uses a song by a convicted pedophile. He's probably making money off it - CNN
And that’s not all.
    Glitter, whose real name is Paul Gadd, is probably making money off the song’s use in the movie, too.
    It’s unclear exactly how much Glitter could make, but attorney John Seay, who specializes in entertainment law, broke down the general process.
    Basically, every song has two copyrights — the publishing copyright (the actual composition of the song, like its words and melody) and the actual sound recording (also known as the master). Because Glitter is a co-writer on the song, he probably owns some percentage of the publishing on the track, Seay said.
    The master is typically owned by the recording company, but Seay said it’s possible that the rights have reverted back to Glitter. Whatever money coming out of the song’s use would also have to get filtered through whatever record deal Glitter has.
    news
    In some countries outside of the US, movie theaters also pay performance royalties for music used in films. ‘Joker’ has already been released internationally, and Glitter stands to make money that way as well. Though single payments from theaters are tiny, Seay said they could add up to a “significant payday.” He’ll also get paid when the movie airs on TV.
    Regardless, Glitter is making money, Seay said. And the amount could be in the six figures range.

    The ethics of using a song by a pedophile

    It’s not just about the money, though. Some are questioning the morality of including the song and bringing profit to a convicted child sex offender.
    Rahul Kohli, a British actor best known for playing Dr. Ravi Chakrabarti in The CW’s “iZombie,” said on Twitter that he enjoyed the movie, but he also expressed that many might feel some discomfort at the song choice.
    Glitter was sentenced in 2015 to 16 years in prison after being convicted of child sex abuse. The British former pop star was convicted of one count of attempted rape of a girl under 13 years old, one count of having sex with a girl under the age of 13 and four counts of indecent assault against girls.
    In 1999 he admitted to possessing child pornography — landing him in jail for four months. Seven years later, while living in Vietnam, he was convicted of sex offenses against young girls and jailed for almost 3 years.
    Though some may claim the use of the song could be an intentional choice by filmmakers, Warner Bros. has not publicly commented. CNN reached out for further comment and have yet to hear back.
    CNN and Warner Bros. are owned by the same parent company, WarnerMedia.
    Despite the wave of controversies, “Joker” is making quite a bit of money — bringing in an estimated $93.5 million in North America alone in its opening weekend. That makes it the highest-grossing opening ever in the month of October.

    The song’s differing contexts

    “Rock and Roll Part 2” is best known to American audiences as the “Hey Song,” commonly played during sporting events. The NFL asked teams to stop playing the song back in 2006, after the musician was charged for sex crimes in Vietnam.
    In 2012, the NFL banned the song from the Super Bowl, as a version of it was being used as a touchdown anthem for the New England Patriots at the time.
      The song was also used as the goal song for several NHL teams, including the Nashville Predators. The Predators nixed the song before the start of the 2014-15 season in the wake of the new charges against Glitter.
      Fans in the US, though, still tend to associate the song more with victorious sporting events, whereas in the UK Glitter’s pedophilia is more widely known.

      Related posts

      ‘Joker’ uses a song by convicted pedophile Gary Glitter. He’s probably making money off it

      (CNN)The controversy keeps building for Warner Bros.’ “Joker” movie.

      The song, “Rock and Roll Part 2,” plays for about two minutes as star Joaquin Phoenix, who plays the Joker, dances down a flight of stairs.
      And that’s not all.
        Glitter, whose real name is Paul Gadd, is probably making money off the song’s use in the movie, too.
        It’s unclear exactly how much Glitter could make, but attorney John Seay, who specializes in entertainment law, broke down the general process.
        Basically, every song has two copyrights — the publishing copyright (the actual composition of the song, like its words and melody) and the actual sound recording (also known as the master). Because Glitter is a co-writer on the song, he probably owns some percentage of the publishing on the track, Seay said.
        The master is typically owned by the recording company, but Seay said it’s possible that the rights have reverted back to Glitter. Whatever money coming out of the song’s use would also have to get filtered through whatever record deal Glitter has.
        In some countries outside of the US, movie theaters also pay performance royalties for music used in films. ‘Joker’ has already been released internationally, and Glitter stands to make money that way as well. Though single payments from theaters are tiny, Seay said they could add up to a “significant payday.” He’ll also get paid when the movie airs on TV.
        Regardless, Glitter is making money, Seay said. And the amount could be in the six figures range.

        The ethics of using a song by a pedophile

        It’s not just about the money, though. Some are questioning the morality of including the song and bringing profit to a convicted child sex offender.
        Rahul Kohli, a British actor best known for playing Dr. Ravi Chakrabarti in The CW’s “iZombie,” said on Twitter that he enjoyed the movie, but he also expressed that many might feel some discomfort at the song choice.
        Glitter was sentenced in 2015 to 16 years in prison after being convicted of child sex abuse. The British former pop star was convicted of one count of attempted rape of a girl under 13 years old, one count of having sex with a girl under the age of 13 and four counts of indecent assault against girls.
        In 1999 he admitted to possessing child pornography — landing him in jail for four months. Seven years later, while living in Vietnam, he was convicted of sex offenses against young girls and jailed for almost 3 years.
        Though some may claim the use of the song could be an intentional choice by filmmakers, Warner Bros. has not publicly commented. CNN reached out for further comment and have yet to hear back.
        CNN and Warner Bros. are owned by the same parent company, WarnerMedia.
        Despite the wave of controversies, “Joker” is making quite a bit of money — bringing in an estimated $93.5 million in North America alone in its opening weekend. That makes it the highest-grossing opening ever in the month of October.

        The song’s differing contexts

        “Rock and Roll Part 2” is best known to American audiences as the “Hey Song,” commonly played during sporting events. The NFL asked teams to stop playing the song back in 2006, after the musician was charged for sex crimes in Vietnam.
        In 2012, the NFL banned the song from the Super Bowl, as a version of it was being used as a touchdown anthem for the New England Patriots at the time.
          The song was also used as the goal song for several NHL teams, including the Nashville Predators. The Predators nixed the song before the start of the 2014-15 season in the wake of the new charges against Glitter.
          Fans in the US, though, still tend to associate the song more with victorious sporting events, whereas in the UK Glitter’s pedophilia is more widely known.

          Related posts