Beyond Cultural Care.

By Sian Hannagan
Jan 2018

For a white woman accessing maternity care in Aotearoa, it is normal to receive care from a midwife or maternity carer who shares your cultural perspective, world view, and indeed skin colour. For Māori, Pasifika, and immigrant communities this is not generally the case. The reality for women who don’t identify as European or white, is that their maternity care is often lacking in cultural competence and the necessary depth of understanding to meet all needs effectively. Having cultural care is a core need, and there is science to back this up. show that women who receive maternity care from someone who shares their cultural background, have better outcomes and greater satisfaction in their care.

For the most part, maternity care in New Zealand is largely white, colonial care, which primarily meets the cultural needs of women and whanau of European descent. As of 2017, 88.5% of our midwife workforce was European, with just 5.7% (174 midwives total) being Māori. This means that Māori women are not always able to access care from a midwife who shares their cultural background. And frustratingly, this disparity only looks to get wider. Māori population is predicted to rise by 16.6% in the next 4 years, yet the number of practising Māori midwives is unlikely to significantly grow in the same period. Enrolments in educational bodies with courses in midwifery are slowly increasing, however, unless we take steps to make our education models inclusive, it may be too little too late.

So why does this matter? Isn’t one midwife as good as the next? The short answer to this, is that in terms of qualifications and skills, of course our midwives are competent, caring and qualified. But when it comes to the larger concerns of partnership, cultural safety and emotional wellbeing, having a midwife or birth care worker who shares your culture actually matters a lot. Particularly when we look at the outcomes for Māori and Pasifika in birth settings. We work with a partnership model, where midwives provide continuity of care. Receiving maternity care that does not meet your cultural needs can have negative outcomes. This is fact. This is not just about how birth care makes us feel, it is about how fundamental inequalities in birth care can cause negative outcomes for mothers and babies – there is mahi to be done.

Fortunately, our healthcare system has identified this need and is working towards being more inclusive. The Ministry of Health have made some clear statements about their goals to increase number of Māori in our healthcare workforce. A key goal is for healthcare that is “people powered” with a strong focus on Māori participation in service delivery.

To celebrate homebirth week, Manawatu Homebirth Association held a screening of the movie Microbirth. I took this opportunity to watch it and see what the message was. Many scientists are stating that Microbirth should be mandatory viewing for every parent, pregnant women, health care professional and physician to better understand the need to protect and nurture the microbiome. This care is vital, not just in adulthood but during the pre-conception period, in utero, in labour, and post delivery including how we feed our babies. In fact, this is the most vital timeframe for our microbiome development.

So, what is the microbiome? It is essentially the population of microorganisms that live in our gut, mouth, skin and elsewhere in our bodies. The term was coined by Joshua Lederberg an American molecular biologist who discovered that bacteria could mate and exchange genes. The total number of genes associated with the human microbiome exceeds the total number of human genes by a factor of 100-to-one. These microbial communities in our bodies have numerous functions relevant to supporting life. They are needed to digest food, to prevent disease-causing bacteria from invading the body, and to synthesize essential nutrients and vitamins.

The movie, ‘Microbirth,’ is about our body and the immune system. It describes our internal and structural “ancient microbiome,” which is there to protect us against many chronic diseases and how it is weakening.

Under Te Tiriti O Waitangi we have a commitment to the following:

Partnership involves working together with iwi, hapū, whānau and Māori communities to develop strategies for Māori health gain and appropriate health and disability services.

Participation requires Māori to be involved at all levels of the health and disability sector, including in decision-making, planning, development and delivery of health and disability services.

Protection involves the Government working to ensure Māori have at least the same level of health as non-Māori, and safeguarding Māori cultural concepts, values and practices.

Ostensibly this means providing health and birth care that meets the cultural needs of the person receiving said care. But is this enough? Will this address the deep inequalities in care that have been created by our colonial past. Because for us to make any real change, it is essential that we understand that our current healthcare model is colonial in nature, that our birth care grew from a concerted attack on Rongoa Māori and traditional Māori birth practices. This is of course alongside the decimation of a culture, language and a people. It’s hard to fix that with an online cultural competency course.

When we view the actions of settling Europeans, it is hard to deny that the goal of colonial people was to wipe out and destroy tikanga Māori. Either by assimilation or outright destruction. The narrative of the scholarly and God fearing white doctor bringing improvements to the heathen natives is not so far in our past that we can pretend it didn’t happen. Truby King wasn’t some anointed saviour, showing us how to raise our babies. He was a white supremacist who took a eugenic approach to improving our race. He has spoken of women as being “densely ignorant”, and thus his self-appointed job was to parent by proxy the infants of our nation. So, Plunket began. Karitane nurses were seen as a force of good in our communities who, despite well meaning intentions, participated in race oppression. Through educating native women out of their own practices; or by denying resources and care. The underlying message was assimilate or die, which could be taken quite literally when the Māori infant mortality rate at the time was four times that of European babies. From Plunket’s own history books, they would only visit Māori mothers who were “living in a European style”.

Plunket Nurses were primarily white and were serving the needs of European families. Many Plunket Nurses refused to visit Māori in their community or refused to see them at all.

Until very recently in our hospitals, whenua of Māori birthing mothers were treated like medical waste, and incinerated. This acts a metaphor for the physical theft of land. For tangata whenua (people of the land), the placenta is more than afterbirth. It is a physical and spiritual connection to the land. . Placenta burial has been a core part of Māori birth tradition symbolising the birth of the people from the land. The fact that in our medical past we took this tradition and turned it into something dirty and unhygienic is paternalism. Acts like these may feel like something in our past that we have since evolved from, but we need to address the fact that our current maternity infrastructure still acts as a tool of severing. Birthing spaces that can’t accommodate whanau, that are void of traditional birth understandings, and a workforce that lacks diversity all add to a sense of disconnectedness and unbelonging. I’ll say it again. Mahi needs to be done.

This 1987 painting by Robyn Kahukiwa, ‘Te whenua, te whenua, engari kāore he tūrangawaewae’, comments on the suppression of this tradition by European-run maternity hospitals which, at one time, insisted on burning placentas.

Too often health care is reduced to a series of statistics and demographics, and health initiatives which ‘target’ our ‘at need’ groups is how we address these health inequities. For Māori this can be a dehumanising process. We talk about teen mothers, obesity and rates of smoking often as if these are specifically Māori and Pasifika issues and this can be problematic in itself, as conversations like this are by default ‘othering’. Midwives as part of their duty of care, are required to deliver health messages that relate directly to these targets. How effective do we expect this messaging to be, if it comes from someone who does not share lived experience or cultural understandings?

Despite a universal provision of maternity care, infants of Māori women are more likely to die in their first year of life than non-Māori infants,2,3 and are more likely to have avoidable hospitalisations with gastroenteritis, skin infections and respiratory admissions. In 2013, the Perinatal and Maternal Mortality Review Committee reported that the babies of Māori women were almost twice as likely to have a potentially avoidable perinatal death compared to babies of New Zealand European mothers (22% vs 12%). Something essential is missing in how we provide care.

When we talk about these outcomes, it is not uncommon to hear conversations about smoking rates, teen pregnancies, violence, obesity and poor living conditions. We have to be careful with how we have these discussions, if we focus only on the outcomes then we lose an opportunity to improve our services in a way that nurtures whole communities, rather than targeting individuals. There needs to be acknowledgement that these outcomes may stem directly from the trauma of apeople through colonisation. Statistics like these only tell only a small portion of the story. They allow us to stereotype and then dismiss. The narrative of the teen mum who is overweight, feeds her baby formula and smokes, feeds very neatly into our culture of uplifting children as a solution to a problem, rather than a symptom of wider issues of cultural neglect.

As someone very wise said to me once, ‘don’t uplift the children, lift up the whanau’

Source: Māori digital stories about caring for kaumatua (elders) at the end of life. Teaching resource for nursing students, nurses and other health professionals who want to know more about Māori whanau (family) end of life needs and priorities.

To turn some assumptions on their head, we need to consider, that to a people who had their population reduced by almost half in less than a century, youthful pregnancy may very well be a cause for celebration. Māori population on the rise, each baby born is a taonga.

Māori health wisdom is fundamentally different to Western paradigms, whose focus is principally the absence of health with interventions to return to a state of health. Māori perspectives on health are often broader, with paths to health being diverse. Understanding health as an expression of community health, spiritual wellbeing, emotional health and whanau health as well as physical health is fundamental to understanding Māori health models. Without such understandings, we can’t hope to address the very narrow birth outcomes that we identify.

When we view healthcare as an extension of meeting Maslow’s Hierarchy of needs it becomes easier to identify where we fall short. As Beverly Chalmers – PhD, discusses in her paper ‘Cultural issues in Perinatal Care’ – “it may be possible to highlight universal needs of women in childbirth rather than universal means of achieving them, by utilising Maslow’s decades-old framework of need hierarchies one can pinpoint the needs of a woman in birth”. She goes on to point out that birthing in the family home assisted by a traditional midwife is a key safety factor for some women. Being able to birth under the eaves with their ancestral spirits is a necessity, but traditions such as these are viewed as completely pointless from a solely medical perspective. If we are to provide true cultural care, we need to accept these needs. We need to concede that birthing well is about more than just the physical safety of a baby and a mother.

To address this thoroughly we need to consider that often what is referred to as scientific or ‘evidence based’ can also mean racist. This might seem like a bold or even ridiculous claim, however when evidence-based means ignoring traditional ways of being and seeking health, then we run the very real risk of acting our oppression on cultures that have different value systems. When we reduce everything down to scientific evidence in absence of the holistic health model, we fail to be integrative. The needs of a woman in birth will vary woman to woman and community to community. Ignoring cultural needs can cause harm.

Maybe our job is to take a step back and create space for traditional communities bring their health approaches to the fore. Cultural care is about more than using bilingual resources or inviting some elements in, sometimes. It is about taking apart structures that treat Māori and Pasifika like statistics, or problems to solve. We need to stop talking about targeting certain groups and start talking about uplifting them, listening to them – and cherishing them.

Useful links and references:

Eugenics in New Zealand

Cultural invasion continued: the ongoing colonisation of Tikanga Maori

The dark unknown story of eugenics in New Zealand

The great silence-the heartbreak of losing te reo

New Zealand midwives accused of racism

Whenua to whenua

Native Women Reclaiming Birth on Their Terms

Indigenous Midwife Advocates Retaining Best Traditional Practices alongside Evidence-Based Practices

Owning the shadow white patriarchal culture in the preceptor and student relationship


Editor’s note:

This editorial deals specifically with Māori health as this an issue specific to Aotearoa, obviously cultural care is relevant at a global level and there are many native communities seeking redress of the healthcare disparities. There needs to be a recognition, that at a global level healthcare has been a tool of colonising nations and when viewed broadly, when used to deny healthcare or to over could be considered an act of genocide. Pasifika birth care outcomes are by necessity tied up in the same arguments, I have referred specifically to Māori in most cases, but Pasifika groups experience the same or similar issues.

It’s important to know that I write this as a white European and that my perspective is inherently limited. I cannot speak to the lived experience of tangata whenua. I can only advocate for their rights to be heard and to receive maternity care that meets all needs

Home Birth Matters

Volume 4 Issue 4

Published continuously since 2013

ISSN 2422-9946Editor: Sian Hannagan

Advertising and Editorial enquiries: Hannagan our Editor