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.

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.

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.

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.

Initiation of maternity care for young Maori women under 20 years of age.

AIM: To explore the lived realities of pregnant Maori women <20 years through pregnancy and motherhood, to identify barriers to, and facilitators of, access to maternity care. METHOD: Using a Kaupapa Maori research paradigm, 44 pregnant or recently pregnant Maori woman <20 years of age were recruited in two case study sites. Participants completed a series of interviews during different stages of pregnancy and motherhood. Interview transcripts were read, re-read and cross-compared by the two interviewing researchers to identify emergent themes, and organised using the software programme Nvivo. Thematic data was grouped, and re-grouped into topic areas for further analysis. RESULTS: Participants engaged early with health care services both to confirm their pregnancy and to initiate maternity care. Barriers to access occurred at the first contact with a lack of information, and support along the maternity care pathway to mainly community based midwifery care. Many participants felt inadequately supported to be able to identify, confirm, and enrol with a midwife or hospital care. Participants who received proactive support at the first interaction with health services had an appropriate maternity care pathway toward obtaining early and seamless maternity care. CONCLUSION: Interviews with participants identified that contrary to published literature young Maori women are engaging early with health services (GP services, school and community based youth health services) for maternity care, but system barriers from this first health contact lead to avoidable delays to them accessing a seamless maternity care pathway. There is a lack of sufficient and appropriate information and support for this young population group who have limited resources and experience to navigate through health services. These inequities in access to maternity care could be reduced through an integrated model of care that sees maternity care beginning at the first interaction with health care services. The service, primarily general practitioners, would then take responsibility for first trimester screening and navigation to a lead maternity carer.

Age standardisation - an indigenous standard?

The study of inequities in health is a critical component of monitoring government obligations to uphold the rights of Indigenous Peoples. In Aotearoa/New Zealand the indigenous Maori population has a substantially younger age structure than the non-indigenous population making it necessary to account for age differences when comparing population health outcomes. An age-standardised rate is a summary measure of a rate that a population would have if it had a standard age structure. Changing age standards have stimulated interest in the potential impact of population standards on disparities data and consequently on health policy. This paper compares the age structure of the Maori and non-Maori populations with two standard populations commonly used in New Zealand: Segi's world and WHO world populations. The performance of these standards in Maori and non-Maori mortality data was then measured against the use of the Maori population as a standard. It was found that the choice of population standard affects the magnitude of mortality rates, rate ratios and rate differences, the relative ranking of causes of death, and the relative width of confidence intervals. This in turn will affect the monitoring of trends in health outcomes and health policy decision-making. It is concluded that the choice of age standard has political implications and the development and utilisation of an international indigenous population standard should be considered.

Mapping the themes of Maori talk about health.

AIM: This paper reports the findings of a qualitative research project that investigated: how Maori talk about health; Maori health; and Maori experiences of interacting with both mainstream and Maori providers of healthcare. METHODS: Twenty eight self-identified Maori were recruited from urban, marae-based healthcare services. Rich descriptions of commonly occurring themes were used to examine participants' experiences, explanations and ideas. RESULTS: Twelve themes provide an overview of how Maori health is conceptualised, the importance of 'traditional' concepts, the experiences of Maori within mainstream healthcare, and Maori health promotion mechanisms. CONCLUSIONS: Providing holistic healthcare to Maori in a respectful and collaborative way will provide opportunities for health professionals to have a positive impact on the health of individuals, their whanau and, in turn, their communities, hapu and Iwi.