The Living Evidence for Australian Pregnancy and Postnatal Care (LEAPP) Guidelines Group is made up of Australia’s leading maternal and child health researchers, clinicians and passionate consumer advocates. Together, they draw on their deep knowledge, skills, lived experience and enthusiasm for collaboration to shape new and updated recommendations for pregnancy and postnatal care in all corners of the country.
This month, LEAPP Co-Chair Dr Nisha Khot shares her insights into LEAPP’s first year, and her hopes for the future impact of the guidelines in the years ahead.
Over the last three decades, Dr Nisha Khot has worked with and for women in rural, regional, remote and metropolitan settings and seen first hand the challenges they face in accessing essential health care. She began her career in obstetrics and gynecology in India in the mid-1990s, before moving on to study and work in the UK and Australia.
‘At the start of my career, the most confronting thing for me was just how little women’s health mattered in the scheme of things,’ Nisha says. ‘You know, you grow up with this very rosy idea that the world is an equal place, and that of course women’s health is just as important as anyone else’s health. But once you get into the specialty, you realise how underfunded and undervalued women’s health is, and how women are undervalued in general. This was particularly striking in India. There was very little value for women’s health or lives – it was like they were dispensable. It was a horrible feeling seeing this. So from the outset, it made me want to work to make a difference to women’s lives, health and well-being.’
While Nisha has seen positive changes to women’s healthcare in the past 25 years, she still sees intractable structural issues blocking progress around the world. ‘While there’s no doubt that there have been positive developments, structural patriarchy is very difficult to shift. So although things may change on the surface, once you start to dig a little bit deeper, you realise that that basic kernel of patriarchy is still there, and that dominates everything that happens upstream. You have to be vigilant in trying to make real change on the ground.’
It’s these kinds of early experiences and ongoing observations that sparked and continue to underpin Nisha’s lifelong commitment to improving and addressing equity for women through all her work – be that in research, clinical roles or as Co-Chair of the Living Evidence for Australian Pregnancy and Postnatal Guidelines (LEAPP).
‘I originally put my hand up for the LEAPP guidelines as they sounded very worthwhile to me, particularly in the context of my interest in equity and diversity. I can bring that lens to reviewing the latest evidence and ensure that together, we’re updating existing guidelines and developing new clinical recommendations with equity, diversity and accessibility in mind. It’s an essential program of work that presents different opportunities and challenges for all the experts who have come together to work on it.’
‘I think we all recognise that reaching consensus is always a key challenge, especially for cross-disciplinary groups that come from very different spheres. We all think our little bit of that particular subject is the most important. But for everyone involved with LEAPP, we know from the outset that our shared aim is to develop consensus-based guidance.’
‘In much of health care, what’s put out there is referred to as ‘consensus-based’, in that a group of experts decide on what they think is probably the right thing to do, based on the little evidence that might be available. But LEAPP differs from that kind of conventional guideline approach in two important respects. Firstly, we have consumers involved right from the get go. That doesn’t happen very often at all. Usually consumers get to see and have a say on a guideline once it’s been written. It’s so much better to have them here with us right from the beginning, having a say on recommendations throughout the whole process.’
‘Secondly, we have such a wide and rich variety of expertise and input into each step of the LEAPP guidelines. All the panel members bring their own particular professional experience and perspective to each topic. So as an obstetrician I look at the evidence with one lens, while an anaesthetist, midwife or psychiatrist will look at it with their respective lenses. Having all these different specialties together in discussions and in the same room is so useful. Whereas with traditional guidelines you’d usually see specialists contacted or brought in at the very end of the process, just as an add-on. With LEAPP we’re all in the same room, all the way along – ensuring input from a genuinely broad base of people, including consumers, midwives, doctors… everyone.’
‘That said, it’s definitely a significant undertaking and an ambitious program. But one year in, we can already see we’re chipping away at it and making a difference. Looking ahead, I’m really looking forward to getting into specific priority areas like diabetes and pregnancy – which we know has been and continues to be a very controversial issue. Researchers and clinicians have gone around in circles for some time trying to answer questions like what are the exact numbers that we use for diagnosis of diabetes? How much should we use insulin? Should we use something else? What are the risks that are involved with someone with having diabetes? There’s been quite a bit of new research in these areas, so I’m excited that as part of the guideline development process we can explore and draw on the latest evidence. Other expert groups are working on that now, so we don’t want to duplicate the work but rather we’ll draw on and build on that in the near future.’
Looking ahead, Nisha is also keen for LEAPP to play a role in getting trusted evidence into the hands of those who need it. This is particularly important given the rise of health misinformation, disinformation and online ‘wellness’ influencers advocating against medical interventions of any kind. ‘We know there’s this growing trend where people will say things like women have been birthing for billions of years and there’s no place for science and medicine in this ‘natural’ process. But actually, when you look at recent history there are many life-saving interventions that ensure women and babies are not dying, maternal and child health mortality rates have improved. So we’ve got to acknowledge that as well. Guidelines can and should bring back that middle ground of providing the evidence and reminding people it’s there. Now you might see the evidence for a particular intervention and decide you’re not convinced by it. Someone else may decide it makes sense and want that intervention. So because we are all individuals, we’re allowed to have different views. The critical thing is to have the updated evidence available.’
‘In this way, I’m really looking forward to LEAPP delivering very clear evidence-based guidelines for key aspects of pregnancy and postnatal care. I’m especially excited about the postnatal guidelines, because while there are a few around, no one has yet developed a suite of really clear postnatal guidelines. At the end of four years we want to have delivered a set of accessible, useful and evidence-based guidelines that will serve all women and healthcare professionals, whatever their circumstances and wherever they live. That way, we really put equity at the very centre of all we do.’