Daily Tech News show is made possible by its listeners, thanks to all of you, including Steve Aderola, Jeff Riesilks, and Tony Glass. Coming up on DTNS, how to keep medical and other private info private, Sarah has an inside perspective on Airbnb's party ban, and Lamar and I describe our just walkout experience at Whole Foods Market. This is the Daily Tech News for Tuesday, June 28th, 2022 in Los Angeles. I'm Tom Merritt. And from Studio Ribbit, I'm Sarah Lane. Also from Los Angeles, I'm Lamar Wilson. And I'm Roger Cheng. The show is pretty soon. We're very Los Angeles heavy today. So you know, we apologize to our East Coast folks. We will get out to Utah tomorrow though, I promise. Indeed we will. All California show today. Let's start with a few tech things you should know. Mac rumors notes that the MaxTech and CreatedTech channels found that the drive read and write speeds of the M2 version of the 13 inch MacBook Pro are as much as 50% slower than the M1 version of the same laptop. Both channels open the laptop up found at the M2 MacBook Pro uses a single 256 gig NAND flash chip. The M1 MacBook Pro uses two 128 gigabyte flash chips. SSD controllers control something called interleaving when handling multiple physical chips and fewer chips can limit peak performance. Both channels found the slow speeds on the model with 256 gigs of storage and M2 model with 512 gigs had similar read and write speeds to that M1 model. Yeah. So it's the two flash chips because you don't have two flash chips. It slows down the read rate. Makes sense. Okay. That's actually not that big of a deal. The game developer Niantic announced a new title called NBA All World. Like other Niantic titles, it's location based with augmented reality like elements. These avatars can play one-on-one basketball games with real world locations providing power ups and customization options. The game will come out on iOS and Android during the next season of the NBA. HTC announced the Desire 22 Pro at 399 British pound mid-range Android phone with a 120 Hertz 1080p display shipping on August 1st. It offers a built-in digital wallet for managing crypto assets and comes with a free NFT. That's nice. HTC also says it's the perfect companion to its announced Vive Flow VR headset, but we're not totally clear at this point what specific integration there is there, if any. If you buy this, email us feedback at DailyTechNuture.com. Waymo VIA is the trucking arm of Waymo and Waymo VIA and JB Hunt Transport Services announced another test of Class 8 autonomous trucks. The test will take place at a six-week period in July and August this year, each truck will have a human safety driver on board as well as a software engineer. Google launched its Google Earth engine back in 2010, providing access to academic researchers and nonprofits. It's now expanded this into a commercial offering for private and government organizations will be continued to be available at no cost for nonprofits, research, and educational uses. All right. Let's talk about the fact that Airbnb doesn't want me to party, Sarah. Yes. Airbnb would love for you to party, Tom, just not at a house that is part of the Airbnb system. Okay, so back in 2020, and this was in the beginning times of our current COVID life that we live, Airbnb issued a temporary, temporary at the time ban of parties at rental houses in order to help reduce the spread of COVID. It's now made this ban on all disruptive parties and events permanent, especially those with open invites. That means maybe there's a house party that's posted on social media and a lot of people know about it and a lot of people are going to show up type thing. Airbnb said it suspended accounts on 6,600 guests for violating the party ban back in 2021. You might say, wow, that's a lot of parties, and it is, but out of some 150 million users, not that many, at least not that many that were deemed to be an issue. At the same time, the company also lifted a 16-person occupancy limit that it introduced back in 2020 as well.  Yeah, the 16-person occupancy limit doesn't mean like three-bedroom houses now have to accept 20 people. It means if you have like a big, big house that could accommodate 30 people up until now, you couldn't let people book more than 16, now you can. The party thing, I was joking because I went to a party, it may have been Verbo, but I think it was Airbnb in Malibu, it was like 25 people and they weren't blasting the music, but they did have a speaker outside and somebody called the cops and the cops very nicely came by and were like, hey, we get this all the time, just turn the music down.  And nobody got in trouble. Nobody got banned from Airbnb. What this is about is massive parties, right, Sarah? Like you're talking about people abusing the privilege. Yeah, exactly. So as a property manager for an Airbnb where I live, I am keenly aware of the rules and, you know, I moved in here and started doing this gig part time just before COVID hit. So a lot of things that seemed like, OK, we'll have to, you know, take case by case if people want to have a wedding here on the property type thing, you know, it turned into, oh, no, we can't do any of that. Can't be done.  And we get a lot of requests from folks to do things that they don't want to they don't want to make seem our events, but they're very clearly events and there have been a couple, not that many, but a couple of instances where people brought amplified music. And all of a sudden I'm like, what are you got? You guys, you can't do that. I'm the one who gets in trouble. I mean, I'm you know, I've got a little license, you know, as the property manager, this is this is not OK. And you should have known that ahead of time. As far as just sort of the wild party stuff, I get why Airbnb is like, I mean, look at the numbers of all of all of our users and so many people who have continued to use this platform, even though life has changed a little bit over the last couple of years, pretty small amount of them were having wild parties. Let's just say no more parties. And that way, you know, nobody gets refunded from the company. If they do something wrong, there's fewer disputes that the company has to deal with because that does happen a lot. You know, if a guest and I have like some sort of an issue between the two of us and I get Airbnb involved, then somebody over there has to figure out who was right and who was wrong. Yeah, I can't imagine. Sorry, I didn't mean to. I can't imagine that they really care on a surface level. Like like like people spending their money, whatever. I think the part of it is it's an assurance issue go can be an assurance issue and more probably just a PR disaster.  Well, which happened back in 2019 or into California, right? They, you know, like that's what started the first more vague ban. And they've just gotten more specific since then. Yeah, it's it's it's funny because, you know, we mentioned the 16 people maximum at the house that I run. There's actually two houses. I mean, it's a pretty big property, but you still can't fit 16 people comfortably in beds. If you if you had 16 people in there, somebody's on the floor or couch or, you know, sleeping bag or on a lawn chair outside or whatever. So we say, you know, here's our cap. This is this is what will make you the most comfortable.  They don't really care. Do you care? And at that point, it has to be a bit of a judgment call of, OK, well, if it's if it's truly more than 16 people at all times.  That would be yours truly. Well, and I feel like that's a great example of why you set the rule harsher than you mean so that because people are always going to push the edge and they're always going to cheat a little bit and like, you know, like, oh, we're not supposed to have any loud disruptive parties or events. But what if we just have a few friends over? It's like you want to keep it in that realm. That that's why exactly really what Airbnb is saying is we don't want masses of people disrupting things and it varies by from place to place. When I went to that birthday party, it was a place where the cops very clearly like people do this all the time. It's not a problem. There's just somebody down the road that always calls it in, you know. So just turn turn your boom box basically down. It wasn't like we had a big PA system or anything. And and and I think it's different in Palm Springs. We rented a place in Palm Springs once where there were clear things of like, you cannot play the radio outside like this that you will get called and you will be responsible. Like it was very like strict in that neighborhood. So it it it changes from place to place. Yeah, I mean, a lot of this really has to do with neighbors. If you know, if if there are 30 people on this property and nobody's doing anything wrong, but the music is really loud. One of my neighbors is going to text to me and be like, Sarah, are you around? Like what's happening here? I mean, maybe not for like an hour or two. But if it went late into the night, yeah, I mean, it's disruptive. And the company is like, we just don't want to be associated with a bunch of disruptive people. So we're just going to go ahead and say no parties. They know there are going to be parties. They're going to be parties. But if you've got a company wide policy, then you at least get some of those folks to go, maybe we shouldn't go through them because it's just going to be a hassle, you know, or keep it smaller.  Yeah. Well, recently, people in the United States have become concerned with protecting their medical data. And several of you have asked us to cover the risks regarding technology, how to protect your privacy. There are multiple examples where the government might attempt to access your data without your permission. So these are tips apply to anyone who wants to legally protect their own privacy from government surveillance. The Verge has a guide up on how to protect your medical data in particular, which is worth a read. We'll have a link to that in the show notes. Yeah, since so many people asked us about medical data, let's go ahead and start there. In the US, if you're not familiar with HIPAA, that's the Health Insurance Portability and Accountability Act, doesn't protect against all non consensual disclosures of your medical information. Does for much of it, but not all of it. Medical personnel may disclose personal medical information if they think a crime has been committed or if they believe criminal activity is happening at the site of a medical emergency, for example, and all health organizations also must give access to health records in response to a court order. One exception is Connecticut, state of Connecticut, where a law blocks other states from subpoena subpoenaing reproductive health related information. And also what's interesting is that HIPAA does not apply to organizations not offering actual medical care. Here's an example, pregnancy counseling organizations that do not offer medical care may collect data not protected from disclosure. Apps that store your health information may not fall under HIPAA's rules, depending on which information they collect. So exercise apps, smartwatch, fitness apps, period trackers and more. So while these kind of apps have not figured in many cases, they almost apply or comply with valid court orders to turn over such information. So now, Tom, let's talk about more about broad information collection. Yeah, yeah. So beyond just medical information, a lot of people worry about ad tracking, you know, tracking your IP address or pixel tracking cookies. The verge points out these are not really known to be used in law enforcement investigations, despite the HIPAA Brown to add tracking. It isn't nearly as personal as you might think. And while personal information could be decoded from it, that takes work. Law enforcement has easier ways of getting more useful data. However, blocking cookies and using privacy protective browsers like Firefox or Brave can reduce that small risk even further. A more common target for investigators would be your search history. And the most common way to find search history is on your unlocked phone. However, search engines also must comply with valid court orders to report search histories they might have stored in the cloud. In either case, your search history can't be handed over if it's not there. So if you wanted to protect it, you could sign out of a search engine. That stops them from associated with your account or use a search engine that doesn't store any of your history like DuckDuckGo or Brave Search. Now, another way to protect your privacy is when you buy something online. If you're purchasing legal items, legal, that you want to keep private, including medical supplies or medicines that you might want to consider using a gift card so the purchase doesn't show up in your credit card records or associated with your personal info in a point of sale app like Square. I thought that was really interesting. And yeah, I know, you know, for a lot of people if you're listening to this for the first time, most of our audience is pretty well aware of privacy. You might be like, OK, what about phone calls and text messages? Also applicable here may also be accessible to investigators. Cell phone network providers may be compelled to provide which numbers you've called or you've texted. And a court can order a search warrant for the contents of text messages and saved voicemails using encrypted apps like Signal would preserve your privacy in a situation like that. Yeah. And same goes for your location data. Mobile devices can collect location data based on things like which cell towers or Wi-Fi access points you connect to. Obviously, some apps will get try to get access to that as well as your GPS data. You can avoid the last the apps by denying an app permission to log your location, but location data from apps and cell phone use or even your web browsing, which could have IP addresses that might be used to narrow down your location is often obtained and sold in bulk by data brokers if you're not blocking it. The data is anonymized, but de-anonymization can be done. It takes effort again. So it's more common for intelligence agencies like Department of Homeland Security type agencies to do that sort of thing. It's not real common for state or local police to go after that. But cell phone providers can be asked to provide location through what's called a geofence warrant. That is something that local and state police often do not even often, but can do. That asks for info on all devices that pass through a certain area linked to a crime, and that way they can try to narrow down and find their suspect. Those are controversial warrants, however, and they're not extremely common yet. So what do you do here? Well, the easiest way to avoid collection of location data that's an important part is to leave a phone at home or completely turn it off. Now, iPhones have a low power mode when off to help locate the phone if lost. It can only be accessed by the account holder of the phone and historical data is not stored. That's important to know if a phone must be left on, you could disable location data collection in the settings for either iOS or Android. Well, have all this information in our show notes, dailytechnewshow.com. I also put it together in an article on my sub stack at techtom.substack.com. If you want to access it that way or share it around that way. And like Sarah said, we know a lot of these are things where you're like, yeah, I know about this, but just a good rundown and reminder of like, here are all the things you can do, here are all the things to consider. And maybe maybe keep you from freaking out about certain things which are less likely to be used than others. Yeah, I thought one of the. Go ahead. Go ahead, Lamar. OK, first. OK, I thought one of the key ones is, you know, if you worried about location data, just simply just turning that knob off, that option off. That just that cures a lot of the ails, a lot of the things you might be worried about just by changing that setting. And so when you know, if you're, let's say, panicking, but if you're concerned about it, that's one huge one to, you know, to turn off, I think it turns out GPS. And then you can also what airplane mode does that also turn off like you're where your location is? Really just kills the cell connection. It'll leave Wi-Fi on and leave Bluetooth on. Bluetooth can be used for beacon tracking and stuff like that. So, yeah, killing location data is probably your bigger deal. And honestly, if you're really worried about it, just turn the phone off is the only surefire way. Yeah. But again, that's going to take away functionality if you need maps or navigation. So there are instances where you you might just want to make sure that, you know, you've got a phone that doesn't have anything else on it. Maybe isn't even, you know, a burner phone that's not associated with your ID as closely or something like that. A lot of a lot of folks who are doing coverage of things in in controversial areas at a friend who was covering the Egyptian uprising, you know, years ago, was doing things like that where you get a burner phone and you put an encrypted tech messaging app that worked worked peer to peer so that it wasn't even going out over the Internet. There's all kinds of really sophisticated things you can do like that. Hey, folks, if you haven't thought about something on the show, but you don't know our email address, well, here it is. Email us feedback and daily tech news show dot com. Amazon wants to sell its cashier lists. Just walk out technology to more stores. It has it in smaller stores like Hudson stores, Sainsbury's convenience stores, some locations in Resort, World Las Vegas, few sports arenas. Amazon Go uses it for those convenience store size location. That's kind of the template for that. But they want to get bigger stores on board. So they've been rolling it out in their own whole foods locations. Amazon Whole Foods launched its first store with just walk out in Washington, D.C.'s Glover Park back in February. And at the time said it expected costs to operate the store would drop 75 percent just just on handling returns and be an inventory management and things like that. The second one of them opened in LA Sherman Oaks neighborhood in March. So since we're so Los Angeles centric on this episode, we were able to head over there and check it out, Lamar. And it was it was kind of fun. It was. It was I remember we went last year, you and I to an Amazon fresh store. And that was an interesting experience because they use as a cart to scan things. This time when we went in here, we have to have the app open on our on our phone. And we scan our app to get in. You got in. OK. I had a little problem because I had to connect my regular credit card to the the app versus the Amazon store card, which can be used online for Whole Foods, but for some reason in store, cannot be used. So that was the best part is that your Amazon card was like, oh, yeah, you can't use that. We don't take that here. Yeah, exactly. But but you got in after that is it. So it was a setup problem. You can also choose to use a credit card that is associated with your account, although apparently not the Amazon card in Lamar's case. You can just use that if you don't want to use the app. You can also do Amazon one, which is their palm scanning. You could set that up. A lot of people may be freaked out by that, but you can do that. Or you could just choose to pay at a register. You could say, like, I don't want to do any of that. And they'll let you in and then you have to pay at a register, which is actually more like self-checkout. There's an employee attendant there, but it's more like the traditional self-checkout you have. Also, you're told to bag as you go, because the one that you mentioned about Amazon Fresh. You have a cart and you scan and it scans the food as you put it in the cart. The whole food store that we went to was like the whole store was the cart and it could tell where you were and what stuff you picked up and put in your cart. So you didn't have to scan.  And in fact, the cart often would mess up for me. Whereas this, I was just grabbing stuff and put it in. They told you to bag as you go because of that. I didn't do that, though. I waited till the end and bagged everything out, which was really dumb. Like, I don't know why I didn't do that. Like, I didn't trust the system, I guess. I mean, so you weren't trying to be defiant. You just were acting more like how you would at a regular grocery store. Yeah, exactly. Yeah, yeah, yeah. Yeah, that was actually funny. I did it mostly. You gave me more credit than I needed there. I did it some, but I was still like, like it felt like a normal grocery store, but I knew cameras are all around me. So it's like, are they really going to get this? Are they going to are they going to scan this correctly? Especially when I put a couple of things back. You know, I think you did the same too, right? Oh, yeah. No, I did the same thing on purpose. I was like, I immediately went to the loose oranges and just like grabbed oranges. Now they're charging you per orange. They're not charging you by weight. So that's the difference here. They're not charging anything by weight in this store.  The bananas, they they didn't want you to go individually. They had them all in bundles of six and they were priced as bundles of six. I was tempted to try to rip one out, but they did have them taped up. So I was like, well, it's very clear that they don't want me to do that. So I'm not going to like fully break the rules. But I was definitely like picking stuff up on the shelf, putting in my cart, then pulling it out and put it back on the shelf. I was walking away from my cart all the time and grabbing things just to see if it could really track me. And that's normal behavior. I do that all the time in a normal grocery store. So I really was trying to do like all the behaviors that I would normally do. Yeah, I thought it was funny. So you were at the hot food bar. We came around there and you got, I believe, some yams. So like the container says, hey, it's 1099 for this container. And you put two in there. And I'm like, Tom, fill it up. It's the same price. Phil, don't get two. It's even worse than that. I put one in there and then you pointed out like it's not by weight. It's by the box. And I'm like, well, I guess I should have at least two, but I really don't want any more. Yeah, you can put anything in there. Yeah, it's my container container based. Well, and imagine the Amazon and be like, if Tom just wants the one, yeah, I'm fine. It's still 1099. If he gets four in there, 1099. Yeah. So yeah, that's I guess that's one way that, you know, I might be taken aback by, oh, this is a different shopping experience than what I'm used to because I'm used to, you know, stuff by weight. We're not everything in produce is by weight, but a lot of it is. For alcohol, you there was a lady, a very nice lady just kind of hanging out. That was her job is to check your ID before you walked into the part of the store that had the alcohol and then you show up your ID. And then then it all worked just like the rest of the store. But you didn't have to to pull out your driver's license to get into the alcohol part. And then I was surprised, Lamar, that when we walked out, we had to scan again. Yeah, we had to scan with our phone or if you use the palm. But yeah, so it's not it's not just easy as like, OK, I'm back. What's up by? So you have to validate that you are leaving so they can mark your time. Yeah, which I don't think at Amazon Go, you have to do it. I think it just scan in and then you just walk. You didn't get to just walk out of the whole foods. Yeah, you had to scan again. I don't know the promise that though. So it's called just walk out right there in the name. Oh, it is. Oh, OK. Well, they lied then, yes. Well, I don't know if Whole Foods calls it that. You're right. But that is the name of the technology. Anyway, we were sitting around waiting for our receipts. That was the other weird part is you walked out and there was no beep.  That was it. It didn't tell you anything. And it took four hours for my receipt to come. Yeah. And I got mine and one. My theory was they actually had somebody looking at the footage. Like, I don't think this is as smart as it is. I'm playing here. But I was like, I wonder if there's someone there validating that you really did get the stuff because for it to take an hour that they had walked out at exactly the same time. Yours took an hour. Mine took four hours. I did get a lot more stuff. But yeah, I don't know. I don't know. There's I was curious about that. Everything was accurate, though. Yeah, everything was accurate. I did end up grabbing some stale cookies. When I got home, I realized they were stale. So I went online, did the did the refund. Hey, I want my money back. No hassle. They didn't say bring it back to the store or anything. They'd say keep them. And so I got my money back instantly. So that was the fast part. You know, I just thought in whole, this is a this is a really good experience. Yeah, I definitely want to try it again and and just experience the convenience of it because it was a little bit like, oh, I'm trying different things out this time. Next time I just want to like, OK, just let me let me get the things I would normally get. You do still have to pay Whole Foods prices as well. Yeah. And it just and to be fair, like it was a nice size store, but it was definitely modified amount of stuff for like like a Whole Foods. We went to before a newer one in our area is much larger. Yeah, but this was more modified, but it had to be for this kind of service to work. Dine in. I did go to the butcher and I got some chicken wings, right? You could still do stuff like that. And I know you got a slice of pizza, but they boxed it up. It wasn't like in some Whole Foods, you can actually eat in the store. You couldn't do that. See, Tom's trying to be nice. I should I got you. Let's just be real. I got two slices of pizza, eight of them in front of him. He's trying to be nice. I am. I was fine. I mean, who just eats one slice of pizza? Come on. There you go. You like it. You get the second one. Yeah. Anyway, that was our just walk out situation. So if you got questions, we'd be happy to answer them. Feedback and DailyTechDewshow.com. Thank you for the on the ground report from Lamar and Tom. That they could be like it could be like a series. Yeah, a whole show. Yeah, I love it. Lamar and Tom go to, I don't know, the next pizza place. And let's do barbecue. Yeah. Just walk out barbecue. Sir, this is time to walk out. Sir, please, you need to pay for that food. This is not a Whole Foods. Well, if you if you like food and you like eating food on vacation, you might say, you know, I want my next vacation to be one of those things, but I also have to work remotely. And if that is your case, Chris Christensen has the perfect website for you. This is Chris Christensen from Amateur Traveler with another tech in travel minute. If you're a digital nomad or just have dreams of working and living someplace else more interesting for a time because you've already managed to or hope to manage to be able to work remotely. Selena dot com, S-E-L-I-N-A dot com is an interesting site, even if you're just using it to dream about travel, because it's a site that is selling you both a co-working space as well as a place to stay anywhere from a private room to a dorm room, as well as activities that you could do with people who are at that place. It's an interesting site. It's colorful and attractive and makes me want to go someplace interesting, predominantly U.S. and Latin America for now. Selena dot com. And this is Chris Christensen from Amateur Traveler. Yeah, Chris, I like I like the exotic locations that they've featured on that site like Chicago. That's very exotic, depending on the neighborhood. I'm from Chicago, so it might be very exotic, depending on where you're coming from. Good point. Yeah. Yeah, it's good. Lovely town. Love it. Wendy said thanks to you, Chris Christensen. Thanks to everybody who sends us feedback. Feedback at DailyTechNewShow.com is where to send those emails. And also a big thanks to you, Lamar Wilson, not only for taking one for the team and getting a slice of pizza or two at an Amazon ghost store over the weekend, but but also being with us today. Let folks know where they can keep up with your latest work. You can find me at Lamar dot TV. I do entertaining unboxings, other fun videos. And doesn't matter where you follow me, I do the same video everywhere. So check me out there. Thanks. Sounds good. We also have a brand new boss to thank. Always makes us happy to thank a brand new boss today. It's Carter. Carter just started backing us on Patreon. Welcome, Carter. And thank you. Oh, Carter, you made my day. Thank you so much. Who will make our day tomorrow? I can't wait to find it. I know. I know it could be you. There's a longer version of the show called Good Day Internet. We roll right into it when DT&S wraps up available at Patreon dot com slash DT&S. But just a reminder, we do this show live. We're on demand, but we're also live Monday through Friday at 4 p.m. Eastern. That's twenty hundred UTC. And you can find out more at daily tech news show dot com slash live. We're back doing it all again tomorrow with Scott Johnson joining us. Talk to you soon. This show is part of the Frog Pants Network. Get more at frogpants.com. The Diamond Club hopes you have enjoyed this brover.


And now it's my pleasure to introduce Dr. Eugene DeClerc. I can tell by the comments that many of you already know his work. Gene is a professor of community health sciences and is the assistant dean for the Doctorate in Public Health at Boston University School of Public Health. And he's a professor on the faculty of obstetrics and gynecology at the Boston University School of Medicine. He has served as lead author on numerous national reports on women's experiences in childbirth and in the postpartum period, particularly listening to mothers 1, 2 and 3, and New Mothers Speak Out. He's the founder of the website, www.birthbythenumbers.org. He was awarded the 2013 Martha May Elliott Award from the American Public Health Association for service to maternal and child health in the United States. Gene, we're happy to hear you. Well, hopefully you can hear me. That would be a plus, I guess. We'll see how this all goes. Let me get any other introductions or can I jump in? Jump in. Okay, I'm jumping. Then let's move in. Let me just see one thing here. So to advance the slide, so I hit this thing at the bottom. There we go. Yes! Cool. So this is the layout of the presentation. The premise of the talk is that, and I know this is going to be shocking to the audience we have, but the premise of the talk is midwives need to be made more central to women's health care at both the community and the facility level. That's going to be the premise. We're going to use the case of rising caesarean rates in part because I was asked to do that, and so I'm going to work through some of the issues around that, but then I want to come back to midwives' critical role in all of this. So this is a framework for quality maternal and newborn care. Mary Renfrew requires that I use this in every talk now, and so I'm presenting it as part of this because I think it actually works in this case. I think a lot of you may be familiar with this from the Lancet special series on midwifery, and I'm going to return to this, but I just wanted to note one thing at the outset, given that much of this discussion will be around caesareans, and that's this, that midwives can be involved in almost all aspects of care, perhaps except this final one where we thankfully have highly trained and skilled obstetrical specialists who can provide care to high-risk cases, but the other point of this was that high-risk cases are rare, so caesareans can be life-saving in those cases. The question for us is how often are they needed? So understanding that this is addressing only one small piece of that, we're going to look at the phenomenon of caesareans because it captures a lot of what people are concerned about regarding maternity care now. So how frequent caesarean sections be, and this has obviously been a question that folks have wrestled with for some time, and so this is a little bit of what the literature says, and people in our area often cite the WHO's recommendation of a 10 to 15% caesarean rate, but that was a consensus meeting. There wasn't actual formal studies that were associated with that, though people have relied on that for some time. Ferdinand Altebi and colleagues did a thoughtful study published back in 2006 looking at caesarean rates and neonatal and maternal mortality, and the references for all these are at the bottom of the slide, and I would encourage people to take a look at them because they're very interesting, well-done studies. And basically what Altebi and colleagues were, they were not trying to target a particular rate, but if you look at the figures from those research studies, what you'll see is two things. One, that very low rates are dangerous, right? Caesarean rates under 10% are often a reflection of a lack of infrastructure in a given country, and there's a need to have enough infrastructure to address what truly emergency cases, and of course in a lot of those countries, the variety of health conditions and social conditions is such that there's a greater need in many cases for dealing with things like obstructed labor. And so in those countries, the very, very low Caesarean rates were reflective of high, or related to very high neonatal and maternal mortality rates, and as the Caesarean rate went up, the neonatal and maternal mortality rates dropped substantially. But after about 15% or so, those benefits decreased, and in middle and high-income countries, when you look at this, those flatten out even more, and there's less and less clear a case for that, but they don't make a formal recommendation. Then more recently, a group that had worked at WHO around this, Yee and colleagues published a paper also in Berth, where they looked at data from 19 industrialized countries, and again, tried to wrestle with the question, at what point the life-saving benefits of a Caesarean section get offset by the unnecessary levels of medical intervention that might be associated with doing Caesareans on women who don't necessarily need them. And they found, interestingly enough, roughly that 10% to 15% range once again. And more recently, Molina and colleagues in the Journal of the American Medical Association analyzed data from 194 WHO countries, and they were looking at data from 2005 to 2012 and either used 2012 data or estimated data from 2012 to do an analysis that's very much parallel to the one that all the being colleagues have done about a decade earlier, looking at its relationship to neonatal and maternal mortality, and they did say, they did come up with a number, and their numbers was 19%. Now, the interesting question here is, of course, what does that relate to actual Caesarean rates?  These are trends in Caesarean rates in industrialized countries, and by industrialized countries, we're talking mostly the countries in what we term the OECD, Organization for Economic and Cooperative Development. And what you can see is there's two flat lines there, one at roughly 15% and one at the more recent 19%. And what you can see is by the early 2000s, most countries were above that, and certainly by 2007 all but a couple of countries were above that, those rates. But if we carry this forward, just to note one other thing, it's not just industrialized countries we're talking about. And another WHO study based on 2008 data, and you see the study there, and it's available online, if you Google that name, you can get the study. What we find is that they looked at the global number in costs of unnecessary Caesareans, and two things stand out from this. One is China and Brazil, both emerging economies but not usually considered among the industrialized countries in the world yet, and accounted for almost 50% of the total number of unnecessary Caesarean sections, both because they have high Caesarean rates and of course they have massive populations. They use 20% in one of their analyses if you use 20% as a threshold rate to say that over 20% means you overuse the Caesarean sections, there's about 4 million Caesareans that are excess in 46 countries that they looked at. And the conclusion is on the bottom pot. Worldwide Caesarean sections that are possibly medically unnecessary appear to command a disproportionate share of global economic resources. Caesarean sections arguably function as a barrier to universal coverage with necessary health services because excess Caesarean section can have important negative implications for health equity as a result of this, both within and across countries because they use up so many resources. And this is just one example of that. It can be deceptive to look at countries and think that they're not in bad shape because their overall Caesarean rate isn't that high. And this is just the case of India drawing on data from demographic and health surveys. And what you see over on the left is for the three periods of time, the early 90s, the late 90s, and the mid 2000s, the rate goes from 2.6 to 7.1 to 9%. And that would seem, you'd say 9%. Well, that's low, that's probably not a problem. But when you break it down by subgroups, you see differences. In the urban population, it actually is up to 17% now. In the high income quintiles, which presumably would be the people who least need Caesareans because they're healthier coming in, the rates were already up to 27%. And that's back a decade ago. And if you were to cross both urban and high quintiles, the highest income groups, what you would find is extraordinarily high rates. And so as much as the large proportion of the problem here is coming from industrialized countries, the challenge that we have is that it occurs, it's increasingly occurring in developing and emerging economies as well. Now, having said all that, I am going to come back to the United States because I have better data on the United States. So this is the United States Caesarean rate for the last 25 years, between 1989 and 2014, which is the most recent data we have available. And you can see the patent, and it's not a patent that's common actually. In most countries there was a clear, consistent increase across this time, but the United States tried to reduce the Caesarean rates in the early 90s, and it had an effect. But since 1996, a tremendous increase, over 50% increase in that time. And so the question is, why was there such a major increase at that point? Here are some of the reasons that I've put forth for it, that it's because mothers are getting older and older mothers are at greater risk, hence they have to have Caesareans. They're more likely to need Caesareans. That because of assisted reproductive technologies is more multiples being born, and because of that they need to have Caesareans. That maternal obesity is a problem, and those mothers are at higher risk, hence they need Caesareans. That babies are getting bigger, because it's a bit ironic, given we're also saying mothers are less healthy, but mothers are healthier than they were before. The babies must be bigger, hence they're bigger, there must be more difficulty, and so therefore Caesareans are necessary. This is in contrast to the next one, which says mothers are generally less healthy. And then there's the argument that this is a function of maternal request, that mothers are asking for Caesareans. Now, the question I pose at the bottom here is what do these explanations have in common, and I think the obvious point is what they have in common is it's not about systems, that it's about mothers themselves, about the babies themselves that's driving this. And in fact, that's a common theme, that it's not us, it's somebody else. So let's look at each of these points in order. This is a question of older mothers. And I would note, obviously this webinar will be available to people to download. Also the slides will be available. People want the specific slides for their own uses to show at parties, to share with friends. That website that's on the bottom of these slides, birth by the numbers, all of these slides will be posted there and people can use them for their own purposes in their own presentations. So this is the issue with older mothers. In the United States, percent of older mothers is tracked from 1990 to 2014. There's a couple of things to note. First, it's true. The average age of mothers was increasing. The proportion of mothers in the older age groups, over 30 and over 35, was increasing between 1990 and about 2004. Keep in mind though, that in the first part of that increase, the Caesarean rate was going down, that since about 2004 to 2010, it flattened and actually went down. And between 2003 and 2010, while the age of mothers wasn't changing, the Caesarean rate increased by 20%. And from 2000 to 2014, it started to go up again. This is partly a result for those not from the United States and not sucked into looking at birth-related data all their lives. This is partly a function of the fact that we've had in the United States a substantial decrease in the teen birth rate. With fewer numbers of teens, the proportion of mothers in the other age categories goes up. But what's intriguing is, while that started to go up, and go up fairly rapidly on mothers over 30, as you can see on the right-hand side of the figure over here, the Caesarean rate's been unchanged. And so it doesn't appear to be much of a relationship at all between the proportion of mothers that are getting older and the actual Caesarean rate. What has changed is this. When you look at the Caesarean rate by age group, what you see is that it's increasing between 45% and 55% in every age group. And if there's any group you might worry about is having such massive increases in women under 20 and under 24, because in a lot of the same societies in which in the United States would be one of them, that vaginal birth after Caesarean is rare, that's going to mean they're going to continue to have Caesareans through the rest of their child-bearing years. So let's look at the second argument. And that's the one about multiple births. And what you see here is proportion of all babies in multiple births in the United States over a 35-year period. And again, what you see is a long increase occurring during the early parts, and this is much of this is related to assisted reproductive technologies. But again, since roughly 2003, that line has flattened out completely. A function of improvements actually in assisted reproductive technologies. What about Caesarean rates? When we look at that, what you see is the change again is in the likelihood of having a Caesarean condition. In other words, the conditions aren't changing as much as the behavior related to those conditions are changing. Let's continue. A baby is getting bigger. This is a very powerful argument. It's a sort of inherently understandable argument, right? That if babies are getting bigger, and that sounds like a good thing because they'll be healthier, then it might lead to problems with the need for more Caesareans. A very powerful, a very effective argument for the slight problem that it's wrong. There is no evidence that babies are getting bigger. Babies are, in fact, if you look at it from the perspective of the babies who might be at greatest risk, between 3,500 and almost 4,000 grams and then more than 4,000 grams, those numbers aren't going up at all. And actually, if you just look at all babies, the numbers go down a little bit related to prematurity. So that's not actually the case. It's not a function of babies getting bigger, though when you see media coverage of rising Caesarean rates, they almost invariably cite this as one of the pieces. But again, what we have seen is this. Caesarean rates for singleton births by birth weight, a substantial change. I think it's noteworthy that you can see in these groups on the left from 91 to 96, either flat or going down through that period, you see the rise between 96 and 2006 and then roughly since then pretty much flat. So the babies on changing behaviors around the babies are changing around the size of the babies. What about mother's health? Again, this sort of lays it on mothers, right? This is rates of pre-pregnancy obesity. I'm going to come back to that issue later. Pre-pregnancy obesity in the United States. And what you see is there was a growth. We don't have as much data on this over time. But you can see there was somewhat of an increase between 2003, 2006, up to 2009, and then level since then. And in overall studies of American society while we continue to refer to an obesity epidemic and rates are higher than they should be, those rates are pretty much leveled off in all populations in the United States at the most part. But this is the trend in terms of cesarean rates for singleton births by pre-pregnancy weight range. And what you see is clear differences in behavior. Now one could argue that obese mothers are at greater risk for other things and this isn't a function of obesity. And I know what your question, your natural question is essentially well gene. Maybe it's a function of other things and have you ever controlled for all of those things? So let's go to the next slide. Oh, we have. This is controlling for a whole range of things. You can see down in the bottom, this is from a study that was in birth last year. And adjusting for age, race, education, prenatal care, nativity and so on, there's still a very, very strong relationship for both first time mothers, that's the blue columns and multiparous mothers, that's the red column and it's almost the same thing in both cases between pre-pregnancy weight and likelihood of a cesarean with mothers in the highest group having more than a double the likelihood compared to mothers in the normal weight range. What about mothers health? Well, maybe coincidental with the cesarean, coincidental with the obesity trends that we saw, what you see is an increase in diabetes and hypertension. It's a little tricky on the most recent hypertension data because they changed the measure slightly in 2014, but in other studies, you see the same kind of pattern here. What's intriguing is when you look at this by cesarean rate. Because what you see is a decline in the early period, an increase, I think some of this change you see at the end is a result of the change in measure, but what you see is an increase in recent years in the likelihood of cesareans, but what I'd really like to point out is this period. If this is solely a function of rates of diabetes and hypertension, the curious part about this is when there was a national effort to reduce cesarean rates, cesarean rates for diabetes and hypertension both went down and the increase has been since then, and at least in the case of hypertension, you see the recent leveling that we've noted in so many of the other cases. So what this all suggests is that the changes we're seeing are a function of changes in systems and how they treat mothers with given conditions far less than mothers themselves and changes in mothers driving that. And then we get to one of the more controversial ones which is mothers asked for this, that mothers ask for cesareans and you see interviews with providers who say it was because of pressure that mothers wanted this. Now initially we have to make one distinction and that's between primary and repeat cesareans, at least in the U.S. context. The likelihood of a VVAC is fairly low in the United States. National rates probably measurement on this is a little tricky, but it's probably around 12 or 13%, which we put it at the lower range if you compare it to other industrialized countries right near the bottom. And in those cases, mothers can't even anticipate the likelihood of having a vaginal birth after a cesarean. So to really understand what we're talking about when we deal with the idea of maternal request, we're focusing primarily on primary cesareans here. And we're drawing data here from listening to mothers, which is a series of surveys I've done with a bunch of fantastic colleagues who sort of carried me through this process. And this is the most recent one, listening to mothers three, which came out now three years ago. And in it we had questions that we've used in the last couple of these surveys. We had two criteria from maternal request cesarean. The first criteria was simply the mother made request for clans cesarean before labor began. In other words, this isn't something that she's raising as an issue in the middle of transition. The second criteria is that the cesarean was for no medical reason. Obviously, if a mother has a particular comorbidity or amorbidity that might be related to a cesarean and that's the driving pattern, then that's not really what we're talking about maternal request. I think when people talk about maternal request, essentially what they're talking about is, again, maternal preference for this. So what happens when we combine these two?  So we asked both these questions at separate parts of the survey and we crossed them to see what proportion of the mothers who had a primary cesarean both made the request for the cesarean before they went into labor and didn't have a medical reason for the cesarean. When you do that, we come out with about 1%. In an earlier listening to mothers back in 2006, it was 4 tenths of 1%. Now, this is not to say it never happens because clearly it does and if one goes online, you'll see references to this on a regular basis from mothers who have done that. And this is a quote from one of the mothers. I think the cesarean is the best way to give birth. It's planned, no hassle, no pain. The baby doesn't struggle to come out and so on. I think everybody should have a baby by cesarean section. But the fact of the matter is, she was far and away the exception to the rule rather than the rule in these cases. And we found almost no cases where we saw the criteria being met. This isn't unique to us. Studies from England, from Canada, some state studies in the United States all confirmed very low rates of maternal request primary cesareans. So let's go back and consider the other side of this. We also asked if mothers felt any pressure to accept interventions based on method of delivery. And so here's the response. The question was, did you feel pressure from a health professional to have a cesarean? This is proportion of mothers who said, yes, by method of delivery. In other words, they have a repeat cesarean, a primary cesarean, a feedback, or vaginal birth. And when you balance these all out, it comes out to be about 12 or 13%, but that's because most mothers still have a vaginal birth. But when you look at this, it's really striking that 22% of the mothers felt they were pressured to have a repeat cesarean. 28% of the mothers were the primary cesarean and 28% of the mothers who ended up with a V-back actually talked about their sense that they were being pressured by their provider to have the cesarean. So this turns the whole argument on its head. This basically says, just when you thought that it was women who were driving it, mothers are saying, essentially, the opposite, that they're feeling pressure from their providers to have it. Some of this is perceptual. If you talk to providers, they do think, they're not making this up. They do think they're being pressured by mothers. And mothers in reverse will feel it from their providers. All right, let's revisit the arguments. So we had six factors here. Age of mothers, more multiples, bigger babies, maternal health, five factors. Obesity, diabetes, hypertension, and maternal requests. So to what extent are these right? Well, first one, older. Mothers getting nup, bigger babies? Definitely not. You can tell because I put some exclamation points after it, so that makes it really important. Maternal health is worse. Yeah, to some extent. There are higher rates of obesity in the past, and obesity is related to caesareans, and there are higher rates of diabetes and hypertension, so that can't be completely dismissed. Mothers are asking for it a handful, but that's hardly indicative of the larger population. So that leads to the question of whether or not a rising caesarean rate is inevitable. And there were certainly studies around this, or at least commentaries around this that suggested, this is a train, we can't stop. A caesarean rate's just going to keep rising and rising as we go forward, and there'll be no way to prevent that continued increase. Well, the answer is no. Some colleagues and I did a study about that. I was also published in birth several years ago, where we saw back then, and this was over five years ago, that caesarean rates, the increase in caesarean rates, it started to slow dramatically, and that's continued to be the case. And in fact, now, let's look at this. This was a slide we saw before of caesarean rates in industrialized countries from 1990 to 2007, and I focus on the fact that most of the countries were above what we either the recommended or targeted rates for caesareans, above 15% or above 19%. If we take this forward to 2013, what you can see is most all of these countries have leveled off. Really, are they continuing to increase through this period? And I think that's sort of good news and bad news, right? The good news is they're not going up anymore. The bad news is they're leveling off at rates far above even the most generous, most pro-caesarean people would generally say are appropriate rates. So it's a bit of a conundrum. We should feel good about the fact that we're no longer on that inevitable rising tide of caesareans. On the other hand, we have to actually reverse this trend and not settle for simply plateauing at unacceptably high rates. One other finding here is that some of this depends on where you started, right? So countries like the Scandinavian countries who generally started with lower rates went up as well, but when they're flattening out now, they're flattening out at 16% and 17% and 18%. And in some of the countries that started out much higher, like the United States, where they flattened out at 32%. All right, so you're saying this isn't the virtual day of caesareans, this is the virtual day of midwives. So where do midwives come in in all of this? Back to this. And where midwives come in is all of this area within the blue frame. The ability of midwives to present all of this is really important at preventing a focus just on medical obstetrics of neonatal services. So let's break these pieces down a little bit. Well, first, some context. This is just a look from the United States of where things stand if you were to look at both proportion... This is by states, in U.S. states. So each of these dots represents a U.S. state. And those of you who are on this from the United States can try to figure out just where your dot is and which state it represents. But if you look at this, you see this general downward pattern, a general negative pattern. In other words, states that rely more heavily on nurse midwives to attend birth, and this would be true if we used all midwives. States that rely more heavily on them have lowest caesarean rates and states that rely less on midwives have much higher caesarean rates. Some of that's inevitable because midwives aren't doing caesareans, so states committed to it are going to have more of a problem with that. But it's important to note this sort of core fact. Okay, so now we look at the components of the framework. For all child-bearing women and infants, they all need this, right? And this isn't happening in hospitals. This isn't happening in facilities, for the most part. But overwhelmingly this is going to happen at the community level. And ideally, especially in this first period, education, information, health promotion, it is going to happen in women's health, not necessarily in prenatal care. In terms of organization of care, the need for competent workforce, the need for midwives. I know in international health that the movement to skilled birth attendance is an important movement, but the movement needs to really have as a foundation an emphasis on midwives for reasons that will become hopefully clearer as I go through this. Continuity services integrated across communities and facilities. And one of the dilemmas we have internationally is the fragmentation of care that people either work in communities or in facilities. And one of the great values of midwives is their ability to work in both and provide a transition point for mothers between both of those. In terms of values, health status isn't a function just of health. It's a function of social context as well. And people who can work in the community and understand women's lives in that community and can empathize and relate to and communicate with mothers around that are going to have a greater impact on that. In terms of philosophy, here's where the prevention comes in. Expectant management, using interventions only when indicated. And the key part to this is that it's not an argument against intervention per se. It should never be. It's an argument against using interventions when they're not necessary. The difficulty is for systems is as they develop and they start building structures to provide these kinds of services, there's going to be increasing pressure to provide these services. Once you staff up a facility, then the economic benefits of keeping that facility running will accrue only if you start going into interventions. And then in terms of care providers, practitioners who combine clinical knowledge and skills with interpersonal and cultural competence is absolutely critical. There's a need for people who are in the community, understand that, can work with mothers, but then provide that transition. You know, one of the great challenges in global health to try to reduce maternal mortality is to get mothers to come to facilities. They don't trust facilities. They're not treated well. They're disrespected and abused oftentimes in facilities. And once that word spreads, there's a distrust in actually using them. What we need is people who can work at the community level and be the transition point to get mothers to facilities when necessary to get services only as they're necessary. Okay. So this is my... I was one of the 97 people who worked on that Lansing series on midwifery. And it wasn't my term. Somebody else came up with the term linchpin, but I'm going to steal it because I really liked it a lot. I thought midwives were really suited to apply these principles in the community where prevention has to begin. Again, waiting until a mother is pregnant is just too late. With respectful care, midwifery and the community bills trust it's necessary to do both these things. I've touched on them already, so I won't belabor it. Convince women of the value and the safety of facility births when necessary in developing countries and provide women in industrialized countries with the support and care that can minimize unnecessary caesareans. Now, why this big push on the community part of it? Well, I'm going to cite another study that I was luckily involved in. You can't wait until pregnancy. Case for community level women's health care. There's not enough time to go into it in great detail, but let me just note this. This is another study we just published. This looks at neonatal mortality by pre-pregnancy body mass index category. What you see there is underweight, overweight, obese one, obese two, and obese three. What it shows is deaths in the first 28 days that's what neonatal mortality is children buy mothers pre-pregnancy obesity controlling for everything we could control for. What you find is strikingly higher rates of neonatal mortality this is in the United States but neonatal mortality based on pre-pregnancy obesity or pre-pregnancy body mass index so waiting until pregnancy is too late. One of the other findings of the study and I won't drill down too far into the study but one of the other findings in the study was even if women followed recommendations concerning weight gain during pregnancy based on their body mass index pre-pregnancy it didn't really actually impact this relationship all that much and so it's getting to women beforehand and midwives are so ideally suited to be able to do that by their nature. Now the other implication for this is going to be around training. The problem itself is in caesareans it's the need for systems of care with midwives in a central role in women's health care in both communities and facilities and the need to recruit and train midwives who can work in both settings who can build a trust in those. It doesn't mean everybody has to do everything but you certainly have to identify train, support, retain midwives who are comfortable in both settings and provide the transition point between those and the results of that will be both better prevention to deal with issues like body mass index as I mentioned better transition in terms of getting women into hospitals when they need to and keeping them out of that when they don't need to be in there and ultimately improving mothers and infants health. All right, I can only talk about this for 17 or 18 more hours but I think there are other speakers. If you want more of this information this is the website I have students who work with this website they're great. We post the data these slides will be posted there you can download them there's considerable other data available as reports there and we basically just try to give everything away so that people can use them in their own context and we're also developing there's some videos up there if you want to present it to groups and we're presenting a whole bunch more on different issues around maternity care. I will thank you so much Gene I can tell you from the chat box people have not been mapping yours I think has been the most popular presentation of the day and I want to thank you for the generosity in this presentation but also the generosity in your birth by the numbers for sharing those data so freely with us that magnifies your voice. There was one recurrent question as you went through the slides. What was the country with the green line that had the highest cesarean section rate? I think I'm going to scroll back. I don't know if people all see this but Brazil Brazil they're asking the lowest green line I believe that is Portugal the lowest green line and let me just amend that again the upper green line is Italy the heavy green line is Italy which has had the highest rate among industrialized countries and also leveled off the lowest is I want to say let's see what is that 12-13% I'm stalling now as I try to pull this up hang on he's almost there it is there was a question about whether you had any data on the diagnosis of cephalopelvic is proportion as a reason for cesarean sections the trends on that have been pretty flat at least in the United States I can't speak to other countries data but at least in the context of the United States that has not been increasing it's a mushy designation by its nature but it has it's up there with fetal distress in a way to convince someone to have a cesarean right away because A if a mother is told either of those babies not fitting through so it's sort of game over at that point but you don't know if that's a diagnosis that's made prospectively or in retrospect as a justification likewise the other one is fetal distress and there's not many mothers who are going to be told that babies in in peril don't worry about it though we're just going to hang out for a while and it's a great way to move mothers I do have the answer that's the Netherlands by the way as the country with that lower with the lowest rate and that's probably a function of the fact that they have a significant proportion albeit a declining proportion of the births happening out of hospital if you were to just look at among the births in hospital in the Netherlands the caesarean rate of about 20% but when you take about 20% of them out of the hospital to be home births then obviously the overall proportion goes down and so part of the reason the Netherlands maintains a low caesarean rate is their commitment to home birth but again that's under fire in the United States I mean in the Netherlands I did see a question about giving voice to mothers there's another survey that's just starting where efforts are being made to try to reach out to mothers who are not part of listening to mothers as much mothers we explicitly excluded home birth mothers in listening to mothers because there simply wouldn't have been enough of them nationally to do much analysis with given our sample size we would only have maybe 10 surveys to deal with and that's not enough to analyze and so there is a survey out now that's giving voice to mothers that's tying it explicitly at mothers from underrepresented minorities and mothers who give birth at home which is also pretty much an underrepresented minority and so I would encourage people if you have one I think we have time for one more question and it looks like Catherine Salam has posted a great one can you elaborate on the intersection between caesarean birth and neonatal morbidity and or mortality yeah so it's again nothing simple when you really start drilling into this it's problematic but the study, the all to be study that I noted before and more recently the Molina study and again there are slides that have references to those both looked at it at a global an ecological level at a national level of the relationship between those and what they found interestingly was that at a certain point and again it was roughly between depending on which study you want to look at 15 to 19% that the rates would start to go up that the neonatal mortality rates would start to go up or flatten that there would be no additional benefit associated with it the reason I say it's a tricky matter is because when you're only looking at infant health oftentimes caesareans aren't bad for the first time, for the first birth they become more problematic in subsequent births because if you have repeat caesareans the likelihood of placental difficulties obviously increases and that can be a threat to mothers and infants in subsequent births but just off of a first birth generally it's not so bad it's not nearly as much of an interest or a threat as it might be but this is very much a problem of decision making so for the clinician who's doing the first birth they have not a great incentive to avoid that caesarean because it might feel well for the baby and the difficulties for the mother wouldn't be experienced until recovery later and that same clinician might not be dealing with that mother in a subsequent birth Thank you so much Jean for setting up for our next presenter I'd like to hear a round of virtual applause for this fantastic presentation I'm going to remember that next time I look at my evaluations My students too, so that works out really well I have a few closing slides to go through Thanks everybody we'll try to share as much I'm going to turn off the recorder first thanks again Jean


Dear students, in this module, we are going to discuss the arranged marriages. Arranged marriages refer to the marriages in which parents or other family members play a key role in selecting potential partners for their children. These marriages are still common in many parts of the world, including Pakistan. Arranged marriages are often seen as a way of ensuring compatibility between partners and of strengthening the family and community ties. If we look at the modern society, most of the love-based relationships are focused on and a flexibility is being established within the society. In Pakistan, particularly youth, they are more interested in love-based relationships as compared to the marriages arranged by their parents. Interestingly, conventional or traditional societies had less divorce rates and more understanding of marital satisfaction. In such marriages, parents or other family members are involved in these relationships. But today, social media has made communication very easy. Especially, our education system is based on co-education. So, it has become more prevalent that two potential life partners should first come into a romantic relationship before marriage and then convert that relationship into a formal legal relationship in marriage. Interestingly, these trends and patterns flow from the life ideologies of western societies. They have nothing to do with traditional or conventional life ideologies. But now that they have become a part of your society, the sociologists have to observe how these trends and patterns are affecting your arranged marriage relationship and are changing it. In other words, the comparative analysis of arranged and love marriages can be seen in how marital satisfaction is involved in relationships. The biggest logic behind arranged marriages in conventional or traditional societies is that these two families are related. That is why relationships are more important for them. The characteristics of the individual partners or their life skills are more important. Since they are more focused on the relationship building, the marriages in arranged marriages are considered the union of two families, the union of two individuals. Similarly, one of the potential benefits of arranged marriages is that in case of certain disputes within the spouses, the people involved in that arranged marriage are also involved in that dispute resolution. Then there are many social support mechanisms developed. In case of certain life accidents in which a life partner is left alone, even in that case, your support mechanisms play an active role in such relationships. And especially in arranged marriages, the provision of children, which is involved in a collectivity and extended family relationships, then the responsibility of the provision of children is also included in that collectivity. Along with this, the disadvantages of arranged marriages may be that the compatibility of married partners is not built and sometimes marriages are possible between incompatible spouses. For example, the age gap may be too much. Similarly, one partner may be highly educated and the other may be uneducated. Along with this, the interests of your life, the goals of your life may not have such incompatibility. So it's a food for thought for you. It's very interesting that you see that in your traditional family system, how arranged marriages strengthen or ensure marital satisfaction. For this, you can interview your grandparents and parents. Along with this, you can also see it from a comparative point of view. Especially in the youth generation in which love marriages are more prevalent.


When I started as a product manager, I always looked for inputs from people to get better at my job, to build better products. Product management is difficult and the community is looking for a guide. Product manifesto is meant to be this go-to guide and set of principles for all BMs to help them set themselves and their products up for success. We need a product manifesto because product management is often misconstrued. There are so many articles and information that creates more noise than signal. And we need product manifesto so it can act as a shared resource, a framework and a guide for all product management professionals and aspirants. A single resource to help PMs apply the best practices that build successful products and successful product careers.


Hello people of the internet, my name is Johnny and welcome back to another phenomenal episode of Special Delivery. As you can see, my streak is back up to 11 and Baby is right here. So, we're gonna unplug our phone and wish me luck boys. Okay, we better get her.  I promise. Hate this!  I don't know what to freaking do! Oh my god. Are you kidding me? I spent so long getting my streak back up. Freaking bloom boys not looking too good now, is he? God. I don't know what I have to do with Baby. I literally feel like I've tried everything. God. And I have to get my streak up back to 11 every single time I want to get her. See now, if Baby went away like that, that would be fine. But she doesn't. She kills me instantly. Understand how I can be any faster. My god.  Oh my god. How can you be any faster? How many cycles does he have? How many freaking cycles? I'm honestly getting really freaking mad at this game. Guess I better get my streak back up to... I... God, I hate this so much. I hate this so much. I hate this so so much. I swear, I've done the exact same thing as everyone else that has ever encountered Baby. I've watched so many videos of everyone else deal with her and I'm doing the exact same thing, I swear. So, it just makes me so freaking mad that I have to get all the way back up to such a high score to the fact that I'm nearly on the freaking leaderboard. It just, it really makes me mad. It's so unfair. This game is so unfair. Like, oh, you want to get high tier characters? Better be rich then. You can put hundreds of dollars into it. I enjoy this game, but my god, it, my god. I think what I'm gonna do, okay, is I'm gonna buy a classic home invasion because that will give me lowers.  Um, but I understand. They gotta make money, blah, blah, blah, blah, blah. I'm still not happy, by the way. I'm still equally as mad as I once back then. So, I am gonna buy it to get lowers. Thanks for my, oh, and it stays as well. Oh, wait a second. That's not what I thought it was gonna do. I thought it was just gonna give me Freddy, Bonnie, Chico, Foxy, Baby, lowers separately. I didn't know that it was a whole set. Well, if we don't get Baby out of this video again, I guess we can say that we did home invasion. I also have four extra batteries, so it should be good. So, the plan, right, I could probably try and get Shadow Bonnie while I do this. The plan is to let home invasion get my streak way up. That's the plan, and then, hopefully, Baby will be back.  I'll be a real mad boy. Oh, it does send them individually. Okay, good. Got a little bit nervous there. Oh, God. Oh, hey. Ooh, it's just a party over at my house, isn't it? Okay, so I was gonna die by Chica, so I just quit out of the round, but it still made me lose my streak. So, I hurry it up, Baby. This is my final attempt. I have loads of batteries, so I'm just gonna leave it on the entire time. No, don't do this to me. Put the haywires. Oh, my freaking God. We got another mod.   Oh, my God, I gotta plug my freaking phone in. And no, I don't want to fight you, bro. That was so freaking intense. All we have left to do is spring trap, and honestly, guys, I don't even know how I'm gonna be able to do that. One, because I've gone to 11 streaks and I have not seen him once.  Even though we do know how to beat him, God, he's so freaking annoying. I haven't really put anything on this endo, so let's see what the mod is, and then honestly, guys, I think I'm gonna end this one here. It might be a bit short, but honestly, I just, I need to stop. Okay, what's this? E-M-G-M-M-K-1. Increase the amount of shake required to clear disruption by 20%. Okay, that's, okay. That's pretty good. And I'll give you a few remnant, man. You earned it. Can I slide it? Thank you. There you go, man.   Send you out to Vapor. I recently added to him. Okay. I gotta end this one here.   Again, I have no clue how I'm gonna do Springtrap. Why? Hello there. Hello there. Freddie, how are we doing? I have no clue how I'm gonna do Springtrap if I can even get to him, because again, I've gone to 11 streaks and I have not seen him once. And I don't really want to pay money to get him, but if it comes down to that, I just may, but honestly, I would rather get up to a high streak and then get him. Also, I really want to get on the leaderboard. If we can't get Springtrap, I at least owe you guys something. So if we don't get him, I'll try my very hardest to get on the leaderboard. So thank you, everyone, so much for watching this video. I hope you enjoyed it.  I just, I can't believe we finally got Baby Guys. That's absolutely incredible. So thank you, everyone, so much for watching this video. Please smash like for my suffering, and I'll see you all on the flip side. Goodbye.


The Lagos State Government has released 11-day programs for the inauguration of Governor Dabajideh Song Olu and his deputy, Dr. Obafemi Hamzad, for a second term in office. Lagos State Commissioner for Information and Strategy, Binggao Motoshino, while unveiling the program, said the 11-day events will hold from May 21 to June 4. He said Song Olu administration has fulfilled the promise of a greater Lagos in many areas of life through the delivery of several live-impacting projects, social investments on the people, as well as economic development of the state. Amatasha, who is the chairman, media and publicity sub-committee of the inauguration committee, disclosed that projects commissioning will take place in eight local government areas of three consecutive days from May, from day three, May 24 to day five, May 26. The promise of a greater Lagos has fulfilled in many areas of our life through the delivery of several life-impacting projects, social investments in our people, as well as economic development of our state. The social contract between Governor Song Olu and the people of Lagos has never taken for granted as chairman of the media and publicity committee to brief you on the week-long activities that we have lined up to celebrate this gentleman who have performed excellently in office in their first term, with the promise of an improved performance with a greater Lagos rising. We are the following events. There will be a public lecture to be delivered by Professor Adi Gunakbagi, the former deputy vice chancellor of the University of Ibadan. The topic will be the making of a Beacon, Lagos and the consolidation of a democracy that works for all. There will also be a book presentation and photo exhibition. Day three, four, five will be for commissioning of various projects in Algeria, Rome, and Belgium, Alimo Oshio, and Ikeja. There will also be projects commissioning at the following locations, Koshofa, on May 26, 2023, there will be projects commissioning in Etiosa, on Lagos Island, Lagos, Maryland, Asurule.