Culturally Safe Neonatal Care: Talking With Health Practitioners Identified as Champions by Indigenous Families.

The burden of health inequities borne by Indigenous peoples can be overwhelming, especially when mothers and newborns' lives are at stake and health services seem slow to invest in responsiveness. In Aotearoa (New Zealand), urgent action is required to eliminate persistent systemic inequities for Maori (Indigenous) whanau (family collectives that extend beyond the household). This Kaupapa Maori (by Maori, for Maori) qualitative study aimed to explore the views of health practitioners identified as champions by whanau of preterm Maori infants. Ten health practitioners were interviewed and asked about their involvement with the whanau, their role in explanations and communication, and their thoughts on whanau coping. Interview data were analysed using interpretative phenomenological analysis. Three superordinate themes were identified: working together in partnership, a problem shared is a problem halved, and sacred space. Collaboration between health practitioners and with whanau was important to the champions and central to their goal of enabling whanau autonomy. This was built on a foundation of connectivity, relationships, and a full appreciation that childbirth is a sacred time that is potentially disrupted when an infant is born prematurely. The values- and relationship-based practices of these champions protected and uplifted whanau. They showed that health practitioners have important roles in both the elimination of inequities and the sustaining of Maori self-determination. This championship is an exemplar of what culturally safe care looks like in day-to-day practice with Maori and is a standard that other health practitioners should be held to.

Getting the Story Right: Reflecting on an Indigenous Rubric to Guide the Interpretation of Mortality Data.

The Family Violence Death Review Committee (FVDRC) is one of five Mortality Review Committees (MRCs) that sit within the Health Quality & Safety Commission, Aotearoa, New Zealand. A key goal of the work of these committees is the reduction of the unequal burden of disparities shouldered by Maori (Indigenous peoples). Guidance to the committees on interpreting and reporting Maori mortality comes from Te Pou (the pillar/post), a Maori responsiveness rubric published in 2019 by Nga Pou Arawhenua (the caucus of Maori MRC members). This guidance was called upon by the FVDRC in the preparation of its sixth report, "Men who use violence," published in 2020. In this article, the FVDRC reflects on how it strove to uphold responsibilities toward Te Titiriti o Waitangi1 in its sixth report to get the story right (Tika-to be correct or true), be culturally and socially responsive (Manaakitanga-hospitability, kindness, support), advance equity, self-determination and social justice (Mana-prestige, authority, spiritual power), and establish relationship for positive change (Mahi Tahi-working together). Opportunities for improved responsiveness in FVDRC reporting are identified, alongside suggestions for extending the guidance in Te Pou. Reflective practice on responsiveness to Maori/Indigenous peoples is recommended more generally for MRCs.

He Tamariki Kokoti Tau: Families of Indigenous Infants Talk about Their Experiences of Preterm Birth and Neonatal Intensive Care.

Maori (Indigenous peoples of Aotearoa New Zealand) bear an unequal burden of poor perinatal health outcomes, including preterm birth. An infant arriving preterm disrupts the birth imaginary of whanau (family collectives) and situates them in a foreign health environment that may not be culturally safe and nurturing. A cross-sectional interpretative phenomenological analysis of first interviews with 19 whanau participating in a Kaupapa Maori (by, with, for Maori) qualitative longitudinal study of preterm birth identified themes from their experiences and the meanings they attributed to them. Preterm birth was an emotional roller coaster, with the birth imaginary and anticipated roles disrupted as health practitioners took over the care of their infants. Whanau expressed the desire to be close to their infants, holding them, loving them, nurturing them, and emplacing them within whakapapa (genealogy, continual layering of foundations) networks. When health practitioners or hospital policies inhibited this intimacy by isolating, excluding, or discriminating, whanau were frustrated. Being familiar with hospital routines, staff, peers, infant cares, and being wrapped in wider whanau support were key for whanau coping. Whakawhanaungatanga (processes of establishing relationships) create safe spaces for whanau to be themselves. This quietens the 'storm' and returns whanau to a sense of calm, through the reclamation of their environment.

He Tamariki Kokoti Tau: Tackling preterm incidence and outcomes of preterm births by ethnicity in Aotearoa New Zealand 2010-2014.

OBJECTIVE: To explore preterm birth among Maori indigenous peoples through Kaupapa Maori research of preterm birth in Aotearoa New Zealand. METHODS: Linked maternity, mortality, and hospital data were analyzed for women and their infants born between January 1, 2010 and December 31, 2014. Relative risks (RR) were calculated for each ethnic group for preterm birth, small for gestational age (SGA), and mortality. RESULTS: Adjusted rates showed that compared with Maori women, European women were at significantly less risk of having extremely and very preterm infants (RR 0.86, 95% confidence interval [CI] 0.76-0.95). Preterm infants of European women had a significantly lower adjusted RR of early neonatal death (RR 0.65, 95% CI 0.45-0.93) or post-neonatal death (RR 0.41, 95% CI 0.26-0.64). In addition to ethnicity, preterm rates were influenced by maternal age, body mass index, smoking status, and SGA status. CONCLUSION: This study demonstrates that the Aotearoa New Zealand maternity system privileges whiteness, suggesting that clinical pathways for evidence-based medical care are not delivered systemically and equitably for all. Health pathways that focus on equity as a fundamental right will enhance health outcomes for Maori women and their infants.

He Tapu Te Whare Tangata (sacred house of humanity): Under-screened Maori women talk about HPV self-testing cervical screening clinical pathways.

OBJECTIVE: To develop an in-depth understanding of HPV self-testing cervical screening clinical pathways for never-/under-screened Maori women. METHODS: Based on a community-based cluster randomized controlled trial in Aotearoa (New Zealand), a Kaupapa Maori (by Maori, for Maori) qualitative study enrolled Maori women who met the eligibility criteria of the HPV trial intervention (aged 25-69 years, no screen in >4 years). In total, 28 were recruited (22 had a negative test, six had a positive test and colposcopy). They were asked about their clinical pathway. RESULTS: The HPV self-test was seen as empowering and promoting bodily autonomy, although some women expressed fears or misconceptions about this new technology. While those with a negative test were relieved, for the six women who had a positive test, there were many fears, compounded by seeking out information on the Internet. When attending colposcopy, the importance of support and responsive care was emphasized. CONCLUSION: HPV self-testing has the potential to improve access to cervical screening and reduce inequities for Maori. Care must be taken in the delivery of screening and colposcopy results. Primary care and colposcopy services need to take special care with never-/under-screened Maori women to provide sensitive, responsive care, and mitigate trauma.

A call for action that cannot go to voicemail: Research activism to urgently improve Indigenous perinatal health and wellbeing.

In this call to action, a coalition of Indigenous and non-Indigenous researchers from Australia, Aotearoa New Zealand, United States and Canada argue for the urgent need for adequately funded Indigenous-led solutions to perinatal health inequities for Indigenous families in well-resourced settler-colonial countries. Authors describe examples of successful community-driven programs making a difference and call on all peoples to support and resource Indigenous-led perinatal health services by providing practical actions for individuals and different groups.

He Korowai Manaaki (Pregnancy Wraparound Care): Protocol for a Cluster Randomized Clinical Trial.

BACKGROUND: Maternal and infant health inequities between Maori (the Indigenous peoples of Aotearoa New Zealand) and New Zealand European women are well documented and cannot be explained solely by socioeconomic status. A research center-iwi (tribal group) partnership aims to address these disparities and improve maternal and infant health outcomes by implementing an augmented maternity care pathway (He Korowai Manaaki) to improve access to services and evidence-informed care. OBJECTIVE: The objective of this study is to test whether an augmented maternity care pathway improves Maori infant health outcomes. METHODS: This is a Kaupapa Maori (by, with, and for Maori) cluster randomized clinical trial involving 8 primary care practices allocated to either an intervention arm or control arm. The intervention arm comprises an augmented maternity care pathway (He Korowai Manaaki) offering clinical care through additional paid health care appointments and improved access to social support (eg, housing, transport). The control arm is usual care. The primary outcome is increased timely vaccination for Maori infants, defined as all age-appropriate vaccinations completed by 6 months of age. RESULTS: Recruitment commenced in November 2018 and was completed in June 2020, with 251 enrolled women recruited in intervention primary care practices before 20 weeks of pregnancy. Publication of results is anticipated in late 2023. CONCLUSIONS: The results will inform primary health care policy including whether the provision of augmented maternal care pathways reduces disparities in the structural determinants of health. If effective, He Korowai Manaaki will strengthen the health and well-being of pregnant Maori women and their babies and improve their health outcomes, laying a strong foundation for lifelong health and well-being. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001155189; https://tinyurl.com/yypbef8q. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18154.

Reaching under-screened/never-screened indigenous peoples with human papilloma virus self-testing: A community-based cluster randomised controlled trial.

BACKGROUND: Indigenous women in the high-income countries of Canada, Australia, New Zealand and USA, have a higher incidence and mortality from cervical cancer than non-Indigenous women. Increasing cervical screening coverage could ultimately decrease cervical cancer disparities. AIMS: To increase cervical screening for under-screened/never-screened Maori women. MATERIALS AND METHODS: This study was a cluster randomised controlled trial. Inclusion criteria were women aged 25-69, last screened ≥4 years ago, in Northland, New Zealand. The intervention arm was the offer of a human papilloma virus (HPV) self-test and the control arm was the usual offer of standard care - a cervical smear. The primary outcome was rate of cervical screening in the intervention group compared to control in Maori, the Indigenous peoples of New Zealand. Six primary care clinics were randomly allocated to intervention or control. RESULTS: Of 500 eligible Maori women in the intervention arm, 295 (59.0%) were screened. Of 431 eligible Maori women in the control arm, 94 (21.8%) were screened. Adjusting for age, time since last screen, deprivation index, Maori women in the intervention arm were 2.8 times more likely to be screened than women in the control arm (95% CI: 2.4-3.1, P-value <0.0001). CONCLUSIONS: Offer of HPV self-testing could potentially halve the number of under-screened/never-screened Maori women and decrease cervical morbidity and mortality. These results may be generalisable to benefit Indigenous peoples facing similar barriers in other high-income countries.

An Affront to Her Mana: Young Maori Mothers' Experiences of Intimate Partner Violence.

Young Maori mothers in Aotearoa/New Zealand are disproportionately vulnerable to intimate partner violence (IPV) due to multiple intersecting factors, such as relationship dynamics during youth, pregnancy, and racialized Maori (Indigenous) identity. An enduring legacy of settler colonialism has resulted in Maori being overrepresented as victims and perpetrators of violence. IPV, in particular, leads to adverse social, mental, and health outcomes over time, including those specific to mothers (e.g., postpartum depression, miscarriage). This study analyzed six narrative interviews with young Maori mothers aged 14 to 19 from the E Hine longitudinal maternal health care study. Kaupapa Maori (by Maori, for Maori) was the primary research framework, which allowed for the use of Maori modes of engagement and the centering of Maori women's voices in the research process. Using a thematic and interpretive phenomenological analysis (IPA), we aimed to understand the lived realities of young Maori mothers who have experienced IPV and to examine the extent to which service responsiveness has been culturally safe. Our findings illustrated how IPV manifests in the relationships of these six women. Their stories showed the various ways in which young Maori women resist violence, reclaim their Maori identities, and experience personal transformation during their motherhood journeys despite abuse. We find that whanau (extended family) is both a violence-perpetuating and immensely protective factor. Moreover, there are structural and institutional barriers to culturally safe service responsiveness for young Maori women. These come in the form of racism at the frontlines of government agencies, pervasive victim-blaming, and a lack of earnest decolonial structural change at the institutional level. We conclude that social services must be multisectoral, culturally safe, and specialized for Maori youth and families to support Maori mothers experiencing IPV.

Improving the quality of mortality review equity reporting: Development of an indigenous Maori responsiveness rubric.

OBJECTIVE: To improve consistency in New Zealand's Mortality Review Committees' (MRCs) analysis, interpretation and recommendations, specifically related to equity and Maori (the Indigenous peoples of Aotearoa New Zealand) mortality. DESIGN: A qualitative Plan-Do-Check-Act design informed by Maori expertise to develop a rubric and guidelines. The rubric and guidelines aimed to improve MRCs' capability to analyse mortality data, its interpretation and the recommendations for preventing deaths. SETTING: New Zealand's MRCs make recommendations to address preventable deaths. Variation existed between the MRCs' understanding of equity, and its application to reduce avoidable mortality for Maori, which subsequently influenced their analysis, reporting and the recommendations generated. Improving the quality and robustness of MRCs' recommendations and reporting are crucial for improving equity. PARTICIPANTS: Maori Caucus (comprising MRC members with Maori health and wellbeing expertise) designed the rubric and guidelines with input from the secretariat and other MRC Chairs and members. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): None. RESULTS: The rubric comprises four key 'pou' (metaphorical posts or domains) 'Tika' (doing things right); 'Manaakitanga' (caring compassionately); 'Mana' (status, authority); and 'Mahi tahi' (working collaboratively); and criteria for three levels of practice. Evaluation of the efficacy of the use of the rubric and its implementation showed further education and support was required. CONCLUSIONS: A shared understanding of equity about mortality is required. Effective implementation of a quality-based rubric into practice requires careful planning and ongoing education and support for staff and committee members at multiple levels. Follow-up support is needed to support its implementation into practice.

Te Ha o Whanau: A culturally responsive framework of maternity care.

AIM: A nuanced healthcare framework, Te Ha o Whanau, aims to make the maternal-infant healthcare system more accessible and culturally responsive for Maori following unexpected events that led to the harm or loss of their baby. METHOD: Te Ha o Whanau was developed from three components. Firstly, it was grounded and informed by Kaupapa Maori qualitative research involving whanau who had experienced the harm or loss of their baby. These learnings were then combined with matauranga Maori (Maori knowledge) and built on three articles of Te Tiriti o Waitangi: Kawanatanga, Rangatiratanga and Oritetanga. RESULTS: Te Ha o Whanau has been developed to specifically guide the maternal-infant healthcare system in providing culturally responsive practice points and guidelines. These practice points and guidelines align with three tikanga Maori (customs): Tikanga manaakitanga, Tikanga rangatiratanga and Tikanga whakawhanaunga. CONCLUSION: To address the stark health inequities present, we must forge innovative models and strategies, rather than reproducing (less successful) paths that have the less resistance. Te Ha o Whanau is provided with the aim of providing better outcomes for all, not just Maori.

Uncovering social structures and informational prejudices to reduce inequity in delivery and uptake of new molecular technologies.

Advances in molecular technologies have the potential to help remedy health inequities through earlier detection and prevention; if, however, their delivery and uptake (and therefore any benefits associated with such testing) are not more carefully considered, there is a very real risk that existing inequities in access and use will be further exacerbated. We argue this risk relates to the way that information and knowledge about the technology is both acquired and shared, or not, between health practitioners and their patients.A healthcare system can be viewed as a complex social network comprising individuals with different worldviews, hierarchies, professional cultures and subcultures and personal beliefs, both for those giving and receiving care. When healthcare practitioners are not perceived as knowledge equals, they would experience informational prejudices, and the result is that knowledge dissemination across and between them would be impeded. The uptake and delivery of a new technology may be inequitable as a result. Patients would also experience informational prejudice when they are viewed as not being able to understand the information that is presented to them, and information may be withheld.Informational prejudices driven by social relations and structures have thus far been underexplored in considering (in)equitable implementation and uptake of new molecular technologies. Every healthcare interaction represents an opportunity for experiencing informational prejudice, and with it the risk of being inappropriately informed for undertaking (or offering) such screening or testing. Making knowledge acquisition and information dissemination, and experiences of informational prejudice, explicit through sociologically framed investigations would extend our understandings of (in)equity, and offer ways to affect network relationships and structures that support equity in delivery and uptake.

He Korowai Manaaki: mapping assets to inform a strengths-based, Indigenous-led wrap-around maternity pathway.

A research partnership between Iwi (tribal group) Ngati Pahauwera and a university-based research centre specialising in Kaupapa Maori (by Maori, for Maori) research was formed in response to an invitation from Ngati Pahauwera. The initial partnership goal was to address health inequities experienced by Maori women and infants in Te Wairoa (the home place of the Iwi), a predominantly Maori, rural region in Aotearoa (New Zealand). The research developed by the partnership is an example of a culturally responsive research methodology. Key features include: being Iwi-initiated; community identification of strengths and assets; guidance by a community steering group; contribution to local Maori research capacity; and the development of a community-led augmented maternity care pathway that is now being delivered through primary care. These features have strengthened the engagement of the Iwi, researchers and community, and provided opportunities for transformative change.

Thinking differently: Re-framing family violence responsiveness in the mental health and addictions health care context.

Aotearoa New Zealand's high rates of intimate partner violence (IPV) and child abuse and neglect point to a clear need to develop and resource equitable mental health and addiction practices that are responsive both to people experiencing and using violence, and to their families. Current responses to IPV in mental health and addiction settings in Aotearoa New Zealand require a critical re-framing, from an individualistic autonomy and empowerment framework that constrains practitioners' practice, to an understanding IPV as a form of social entrapment. Using a composite story constructed from 28 in-depth New Zealand family violence death reviews, we highlight current problematic practice and discuss alternative responses that could create safer lives for people and families. Re-framing IPV as a form of social entrapment acknowledges it as a complex social problem that requires collective steps to secure people's safety and well-being. Importantly, a social entrapment framework encompasses interpersonal and structural forms of violence, such as the historical and intergenerational trauma of colonization and links to ongoing structural inequities for Maori (the indigenous people of Aotearoa) in Aotearoa New Zealand.

Acceptability of self-taken vaginal HPV sample for cervical screening among an under-screened Indigenous population.

BACKGROUND: Human papillomavirus (HPV), the causative agent of cervical cancer, can be screened for using self-collected vaginal samples (self-testing). This may overcome barriers to screening for Maori women who suffer a greater burden of cervical disease than New Zealand European women. AIMS: This study aimed to explore the potential acceptability of HPV self-testing for never/under-screened (self-reported no cervical screen in 4+ years, aged 25+) Maori women by Kaupapa Maori (by, with and for Maori) mixed methods, involving hui (focus groups/interviews) and survey. MATERIALS AND METHODS: Community-based researchers ran hui with women in four regions (N = 106) and supported hui participants to collect survey data (N = 397). Healthcare providers (HCPs) were also interviewed (N = 17). Hui data were thematically analysed. Survey data were analysed by age group, rural/urban, primary health organisation (PHO) enrolment, and time since last cervical screen. RESULTS: Most survey participants were PHO-enrolled (87.15%) and attended regularly (71.79%), but did not attend regular cervical screening. A desire for bodily autonomy, including whakama (embarrassment/shyness/reticence), was the most frequently cited barrier. Three in four women reported being likely/very likely to do an HPV self-test. Nine in ten women reported being likely/very likely to attend follow up if they receive a positive HPV test result. Women and HCPs in the hui emphasised the importance of health literacy, cultural competence and empathetic support. CONCLUSION: The findings indicate that with a culturally competent introduction of HPV self-testing, many currently never/under-screened Maori women would be willing to be screened and followed up if necessary. HPV self-testing has the potential to save lives.

He Tamariki Kokoti Tau-Tackling Preterm: a data-linkage methodology to explore the clinical care pathway in preterm deliveries.

BACKGROUND: Significant health inequities exist around maternal and infant health for Maori, the indigenous people of Aotearoa New Zealand - and in particular around a premature (preterm) delivery. Maori babies are more likely to be born preterm (8.1%, compared to an overall rate of 7.4%) and they are more likely to have a preterm death. An essential part of redressing these disparities is to examine the clinical care pathway and outcomes associated with preterm deliveries. This paper describes a protocol utilising national and local health collections to enable such a study. DESIGN: This is a retrospective cohort study comprising 5 years data pertaining to preterm deliveries from 2010 to 2014. These data are generated from linked national administrative and local health information collections to explore a range of neonatal outcomes and infant mortality in relation to the antenatal care pathway and known risk factors for preterm delivery. This study is being conducted within a Kaupapa Maori paradigm that dismisses victim blaming and seeks to intervene at structural levels to improve the health and wellbeing of Maori whanau (family). SIGNIFICANCE OF THE STUDY: Our data-linkage methodology optimises the utility of New Zealand health collections to address a significant health issue. Our findings will fill the information gaps around the burden of preterm delivery by quantifying the incidence of preterm delivery and adverse neonatal and infant outcomes in Aotearoa New Zealand. It will explore access to evidenced based care including use of steroids before birth, and appropriate place of delivery. The results from this study will inform maternity care services to improve management of preterm deliveries - both locally and internationally. This in turn will improve the preterm sequela by reducing the long-term health burden and health inequities.

Implementing non-invasive prenatal testing into publicly funded antenatal screening services for Down syndrome and other conditions in Aotearoa New Zealand.

BACKGROUND: Non-invasive prenatal testing (NIPT) is a relatively new screen for congenital conditions - specifically, common fetal aneuploidies including Down Syndrome. The test is based on isolating freely circulating fragments of fetal-placental DNA that is present in the mother's blood. NIPT has a superior clinical performance compared to current screening, and has been available privately in Aotearoa New Zealand for the last 4 years. MAIN ISSUE: The proposed implementation of NIPT as a publicly funded service may widen the inequity in access to optional antenatal screening that already exists in this country. CONCLUSION: This paper discusses precautions that can be taken at the health system, organisation, and personnel levels to ensure that access to NIPT is equitable, that services are culturally responsive, and women's informed choice is promoted and protected. The adoption of NIPT into publicly funded services is an example of how genetic screening is becoming mainstreamed into health services; as such our approach may also have relevance around the introduction of other genetic and genomic screening initiatives.

Pounamu: E Hine: access to contraception for indigenous Mãori teenage mothers.

INTRODUCTION Timely and equitable access to contraception enables teenage mothers to make informed choices about their sexual and reproductive health. This study aimed to identify barriers and facilitators to contraception for Maori teenagers who become mothers. METHODS 'E Hine' is a longitudinal qualitative Kaupapa Maori (by Maori for Maori) study involving Maori women (aged 14-19 years), following them through pregnancy (n = 44) and the birth of their babies until their babies' first birthdays (n = 41). This analysis focusses on contraception access pre-and post-pregnancy. FINDINGS Pre-pregnancy most participants accessed contraception or advice. Contraception use was compromised by a lack of information, negative side effects, and limited follow up. All reported their subsequent pregnancies as unplanned. Participants gave considerable thought to post-pregnancy contraception. Despite this many experienced clinical and service delays, financial barriers, and negative contraceptive side effects. There was little focus on contraception initiation and a lack of integrated care between midwives and other primary care services, leaving many participants without timely effective contraception. The system worked well when there was a contraception plan that included navigation, free access, and provision of contraception. CONCLUSION The majority of participants actively sought contraception pre- and post-conception. Despite a publicly funded system, a lack of health sector integration resulted in multiple missed opportunities to meet the needs of these teenagers for effective contraception. Health service funding formulas should define the goal as initiation of contraception rather than advice and provide funding to improve timely access to long acting reversible contraception. KEYWORDS Indigenous teenage pregnancy; contraception; barriers to contraception; Maori mothers.

Understanding Overrepresentation of Indigenous Children in Child Welfare Data: An Application of the Drake Risk and Bias Models.

Child welfare data collected for administrative purposes are often used as a source of information for understanding the population impact of child abuse and neglect (CA/N). This study used administrative data linked at the individual level for a cohort of Aotearoa New Zealand (NZ) children to follow and extend a model developed by Drake et al. In this investigation, we aimed to build an understanding of the high representation of indigenous NZ children in administratively sourced measures of CA/N. Variation in rate ratios (RRs) within infant mortality and birth outcomes considered as possible proxies for actual CA/N RRs leaves open a range of interpretations. Our findings indicate that a more nuanced interpretation of the overrepresentation of indigenous children in administratively recorded maltreatment statistics is required. Rather than considering risk and bias as competing explanations, we suggest an acknowledgment of the impact of colonization and the existence of systemic bias generating increased risk as key drivers. As linked administrative data are increasingly used for research and evaluation, and considered for use in supporting decision making, there is a need for a deeper understanding of the drivers of administratively recorded CA/N in order to effectively address the needs of indigenous populations.