INTRODUCTION

Inequalities in health between Māori and non-Māori have consistently but unacceptably become the norm in New Zealand, a feature that Māori society shares in common with the Indigenous people of Australia (Robson & Harris 2007).

Midwives make an important contribution to improving Indigenous health in the context of their role. This chapter draws on the experience of Māori as the Indigenous people of Aotearoa¹ New Zealand.² It discusses sociopolitical, philosophical and cultural issues of relevance to the health and wellbeing of Indigenous peoples, and thus for pregnancy and childbirth among Indigenous women. It also highlights a number of challenges for midwives working in partnership with Māori women, their babies and whānau (social network), and discusses how midwives and midwifery organisations can make a positive difference in promoting the wellbeing of women and their babies that has wider health benefits for their whānau and for New Zealand society at large.

COLONIAL HISTORY AND MĀORI HEALTH

‘Māori health status today is demonstrably poorer than other New Zealanders’ (Ministry of Health 2002, p vii). The reasons for the differences are complex, but midwives need to understand how the context of the colonial history of New Zealand has influenced both Māori health in general and Māori women’s health, particularly health during pregnancy and childbirth.

Māori were once the predominant occupants of Aotearoa with a distinct language and philosophical and intellectual frameworks. Social, political, economic and education systems were underpinned by Māori philosophy and daily life was organised around a subsistence way of living that was the norm for Indigenous peoples. The land was a source of sustenance that provided a means of survival and an economic base. The personification of landmarks represents a distinct philosophical approach to human relationships with the natural world, a commonality Māori share with other Indigenous societies (Kawagley 2006). More importantly, Māori ancestry is imbued in the natural world, in its widest sense, and every phenomenon is explained by whakapapa (ancestry) (Marsden 1989). The intimate knowledge that Māori have of their natural environment, which includes the land, relates to their ancestral connections to the natural elements, knowledge of which has passed from generation to generation through oral and creative traditions. Dislocation from the land, therefore, has major implications for the health and wellbeing of Māori society.

James Busby, a British resident in New Zealand, drafted the first agreement between the British Crown and Māori, the Declaration of Independence (Appendix 9.1) that was signed in 1835. The Declaration emerged because of Busby’s concern about the lack of a formal justice system according to his understanding of what it should look like, and because of his fears that France would declare sovereignty over the land (Te Puni Kōkiri 2001). The Declaration was acknowledged by the King of England, William VI, but it proved to be a barrier to the annexation of New Zealand by the Crown, which was a growing imperative because of increasing French interest and other interest from the United States (Te Puni Kōkiri 2001). William Hobson, also a British representative, was thus instructed to prepare another document, the Treaty of Waitangi (Appendix 9.2), and he was to ensure that any chiefs that were signatories of the Declaration were also signatories to the Treaty (Te Puni Kōkiri 2001).

From the view of the Crown, the Treaty superseded the Declaration (Te Puni Kōkiri 2001). For Māori, however, the Treaty strengthened their rights to self-determination inherent in the Declaration and, in contrast to theories that Māori ceded sovereignty over their land, they did not agree to the unqualified transfer of their authority to the British government (Belich 1988; Walker 1989). Māori understood that they were active participants in the governance of their own lands and they were equal members of society, at least as it was written in their own language (see Appendix 8.2).

A primary source of decades of dispute between the Crown and Māori relates to the two texts of the Treaty, the Māori text and the English text. The Māori text was signed by over 500 Māori chiefs, including 13 Māori women, initially by chiefs at Waitangi in the Bay of Islands on 6 February 1840 and then by chiefs throughout the country (Waitangi Tribunal 2009). The different texts represent two different systems of a society, Māori and English. Each has distinct philosophical and intellectual origins, from which arise political, ethical, social, justice, education and economic systems. Translating the points of difference between the two traditions of a society is problematic (Durie 2005; Salmond 1985). For example, the Second Article of the Treaty in the Māori text uses the words ‘tino rangatiratanga’. Tino rangatiratanga is a multi-layered concept which, when applied to the land and taonga (things of value), refers to ideas like self-governance, autonomy, guardianship and protection. The English version of the Second Article describes concepts of ownership, individual title, and full and exclusive rights of lands, forests and fisheries. Individual land title and ownership as understood by English society was a foreign concept in Māori worldviews (Marsden 1989; Royal 2002).

Once the Treaty of Waitangi was signed, the Constitution Act of 1852 made provision for New Zealand’s parliamentary system, based on the British Westminster model. The first elections were held in 1853, and Parliament sat for the first time in 1854. The right to vote was based on the possession of individual property and so Māori, who possessed their land collectively, were almost entirely excluded from voting for Parliament (Ministry for Culture and Heritage 2009).

Land loss occurred insidiously through a range of mechanisms, most notably through various pieces of legislation, and this loss caused Māori to become dislocated from their traditional lands. The Native Lands Act 1862, the New Zealand Settlements Act 1863, the Suppression of Rebellion Act 1863, the Māori Affairs Act 1953 and the 1967 Māori Affairs Amendment Act were all introduced to confiscate or compulsorily acquire and sell Māori land. Māori were imprisoned without trial and without compensation, all because of efforts by the Crown to ensure substantive British sovereignty over Māori, which lay at the core of much tribal conflict with colonial armed forces (Belich 1988). Specific legislation such as the East Coast Land Titles Investigation Act 1866 was also introduced to widen enforcement powers in specific parts of the country, and within 20 years of the Treaty, Māori land was reduced from some 64 million acres 26 million hectar to 24 million acres 8 million hectar. Individualisation of land titles was promoted, affecting the integrity of Māori social structures at a time when the fundamental base of the Māori collective was critical for maintaining Māori cultural identity (Belich 1988; Durie 2005).

By 1901 the Māori population had declined dramatically from approximately 150,000 to just over 43,000 (Durie 2005). The decline corresponded to land loss, but other contributors were musket warfare, starvation and diseases (Durie 1997). Measles, smallpox, yellow fever, cholera and typhoid fever were examples of diseases that arrived with large-scale immigration. Although a cowpox vaccine to protect humans against smallpox was found in England in 1796, it was not until the 1830s that significant distribution of the vaccine across Britain occurred, and the task of transporting vaccines over long distances was problematic until the advent of refrigeration (Dow 1999).

The settlers also introduced Western medicine into New Zealand. A comparison with Māori health systems was inevitable, and Māori experts or tohunga underwent increasing scrutiny. The Tohunga Suppression Act 1907 was introduced to prevent questionable practices by some tohunga who, because of a following among their own communities, were identified as a barrier to the effective management of infectious diseases such as tuberculosis. Māori doctors who trained in Western medicine, Maui Pomare and Peter Buck, were positively disposed to the Act, and they were supported by Māori leaders Apirana Ngata and Turi Carroll. The Act, however, also served another political purpose—to control and enable the arrest of Māori leaders such as Rua Kenana, who prophesised the expulsion of Pākehā from the country (Durie 2005). Although the Act was later revoked and it contained no specific reference to traditional healing, it cast aspersions upon legitimate experts in a range of disciplines, all of whom were considered tohunga, thus contributing to the demise of traditional knowledge institutions (Dow 1999).

Mission schools run by churches and private enterprises were the first English model of education introduced into New Zealand. Christianity brought with it the introduction of reading and writing, and it provided a different understanding of religion. Māori could easily relate to the principles and truths of Christianity, which were consistent with Māori philosophy (Newman 2006). Missionaries had a prominent role in establishing settler education while at the same time spreading the messages of their faith (Waitangi Tribunal 2009).

The Education Ordinance of 1847 first provided for government funding of mission schools (Waitangi Tribunal 2009). Schools were required to teach in English in order to benefit from state subsidies. Continued support for mission schools continued via the Native Schools Act 1858, which was only effective for seven years as wars between colonial forces and Māori forced the closure and abandonment of mission schools in 1865 (Waitangi Tribunal 2009).

The Native Schools Act 1867 was an extension of the 1858 Act. The government offered state village schools to Māori communities, which were required to provide a site; and in return they received a school, a teacher and books. Not all Māori communities had a Native School, and it was not until the Education Act 1877 that the government took the first step towards centralised control of education nationally. The curriculum was primarily designed to provide for the education of Pākehā (non-Māori) children. Modelled on a British system of education, Māori children were prevented from speaking Māori (Broughton et al 2001), and the education system was a key instrument of colonisation through a process of assimilation.

The implication of a monolingual education system was that by the mid 20th century, use of the Māori language by Māori had declined so significantly that it was in danger of becoming extinct. By the early 1970s, the number of Māori who could speak their language declined to 18%–20% and most of those people were over the age of 65 years (Te Taura Whiri i Te Reo Māori/The Māori Language Commission n.d.).

In 1972 a Māori Language petition, signed by 30,000 people, provided Matiu Rata, a Māori politician, with sufficient basis to convince the Kirk government to accept the idea of a tribunal to hear Māori Treaty claims (Te Taura Whiri i Te Reo Māori/The Māori Language Commission n.d.). The result was the Treaty of Waitangi Act 1975, which established the Waitangi Tribunal to make recommendations to the Crown on claims relating to the practical application of the Treaty. The Act was later amended by the Lange government to allow claims dating back to 1840 to be heard.

The First and Second World Wars, as in other countries, provided a temporary distraction from a focus on local politics and priorities. Māori mostly lived in rural areas and upon their papa kainga (traditional settlements). However, by the 1930s many young Māori whose whānau had been dispossessed of their lands began moving to towns and cities in search of employment, accelerated by opportunities that were created by wartime industries. By 1951, the proportion of Māori living in urban areas was more than twice that of the pre-war figure of 9%. The dislocation of Māori from their traditional and social support systems consolidated their dislocation from their cultural norms, practices and ethics (Te Rōpu Wahine Māori Toko i te Ora 1984, 1993).

Gaps between Māori and non-Māori with respect to housing, university study, vocational apprenticeships, death rates and crime from about 1929 to 1959 were identified in the Hunn Report (Hunn 1961), commissioned to report on the Department of Māori Affairs. The author, JK Hunn, questioned Māori concepts of land ownership and customary title and did not favour Māori tribal social structure (Hunn 1961). Accordingly his report called for social reform of Māori, and the relocation of Māori from rural to urban areas became official policy (Meredith 2009).

Concerns about the health of Māori women, specifically, emerged from the findings of a study by the Māori Women’s Welfare League (Te Rōpu Wahine Māori Toko i te Ora 1984). Not only was their research significant by being the first quantitative research of Māori by Māori, but the League took the unusual step, for its time, of asking Māori women about their own health (Durie 2005). Their research reported that violence in the home was a significant finding arising from an abusive relationship, insecurity and inability to cope with the stressful environment resulting from abuse. Obesity, smoking and, to a lesser degree, alcohol were also identified as common concerns for Māori women, predisposing to preventable illnesses (Te Rōpu Wahine Māori Toko i te Ora 1984).

Reasons for diminishing health status and wellbeing among Māori were explained by the 1988 report of the Royal Commission on Social Policy. The report emphasised the ongoing impact of earlier legislation and government policies to explain the differences in health, justice, employment and education between Māori and non-Māori. Such differences were found to have a basis in breaches of the Treaty of Waitangi that could be traced back to the arrival of colonial settlers. The Commission emphasised the importance of three principles arising from the Treaty of Waitangi—‘partnership, participation and protection’.

While the Treaty principles capture the intention of the Treaty in relation to social, commercial and health legislation and policies, the principles cannot be understood in isolation from the full context of the Treaty, nor from the communities for whom the Treaty is intended. To date, application of the Treaty principles has relied on goodwill rather than on deliberate and consistent engagement, best illustrated through the inconsistent application of the Treaty or its principles to all legislation. This suggests that the Crown considers the Treaty to be only relevant to certain aspects of the lives of Māori society.

Breaches of the Treaty underpin claims to the Waitangi Tribunal. A common myth is that Treaty-based complaints and the Tribunal process pose a threat to the future of the country because Māori, the minority, are perceived to have power over government and receive special treatment above other sectors of society (Berry 2006; Brash 2004). This fallacy is underpinned by inaccuracies about Treaty of Waitangi grievances and a lack of understanding about the link between the Treaty and its intent, and the cumulative effects on a specific part of society, Māori. Persistent misinformed attitudes overshadow the potential of the Treaty as a philosophical framework for relationships within New Zealand. To this day, the Treaty is the only constitutional document that recognises Māori as tangata whenua (people of the land) and sanctions a relationship between Māori and other New Zealanders (Jackson 2006; Sykes 2007).

New Zealand’s colonial history provides insight into the relationship between the Crown and Māori society. It helps to illustrate some of the reasons why Māori, as a society, are fervently passionate about the significance of the Treaty of Waitangi. The historical backdrop also explains the implications of actions by the Crown on Māori society that have contributed to their health status, through a range of imposed structures. From an understanding of determinants of health and historical matters that underpin the health of Māori today, midwives can then identify ways to influence change, within the context of their role, that have a positive effect on Indigenous health and wellbeing.

AN OVERVIEW OF MĀORI HEALTH STATISTICS AND CONTRIBUTING FACTORS

Māori make up approximately 14.6% of New Zealand’s population (Statistics New Zealand Tatauranga Aotearoa 2007a). Europeans, the largest group, comprise 67.6% of the population (Statistics New Zealand Tatauranga Aotearoa 2007b).

The Māori population is younger than the European population, with 35.4% of the Māori population aged less than 15 years and 4.1% aged 65 years and over (Statistics New Zealand Tatauranga Aotearoa 2007c).

The total fertility rate for Māori women is 2.88 births per woman, well above the rate for the total population of 2.14 births per woman. Māori women tend to be younger than women of other ethnicities when they give birth, with a median age of 26 years compared with the median age for Pacific, Asian and European women of 27, 30, and 31 years respectively (Statistics New Zealand Tatauranga Aotearoa 2009). By 2021, the Māori population is projected to comprise 17% of the population, and the growth is mainly attributed to a higher fertility rate combined with a younger age structure (Statistics New Zealand Tatauranga Aotearoa 2007c).

Māori women have larger families than women from other ethnic groups (NZHIS 2007). In 2004, births to Māori and Pacific women comprised 19.9% and 10.1% of all births respectively, whereas their respective populations of women of reproductive age were 15.3% and 6.0% (NZHIS 2007).

Māori women are more likely (81.9%) than other women to register with a midwife for their care. Māori women were among the highest proportion of women who had their planned home birth occur at home (Ministry of Health 2007b). In hospital, Māori women have traditionally tended to have lower rates for induction and epidural administration than other women (NZHIS 2007). In 2004, Māori and Pacific women were both more likely to have a normal birth (spontaneous delivery without assistance) compared with women of other ethnic groups, and they were less likely than European women to have a caesarean section, acute or elective (NZHIS 2007).

Early detection of abnormalities is a key objective of antenatal care to decrease morbidity and mortality among women and babies. Mortality rates increase with increasing socioeconomic deprivation, and Māori are disproportionately represented in the most deprived areas and are therefore at higher risk of death overall compared with non-Māori (Robson & Harris 2007).

Māori women have the highest rates of lung cancer in the world; twice as many Māori women as non-Māori women smoke, and many of those smoke during pregnancy. Socioeconomically deprived women are also more likely to continue to smoke past the first trimester of their pregnancy (McLeod et al 2003; Public Health Intelligence 2008). An analysis of data from 61,000 women who had a midwife as their lead maternity carer (LMC) between 2004 and 2007 showed that the greatest reduction in smoking behaviour was among women under 25 years of age and Māori women (Dixon et al 2009). The study confirmed that women who identified as Māori had higher rates of smoking at registration with a midwife, but they were also the group which had the greatest reduction of smoking at discharge from midwifery care, a finding consistent across each year of the study’s analysis.

Perinatal conditions (premature birth in particular) and sudden infant death syndrome are consistent major causes of death among Māori babies (Pomare et al 1995; Robson & Harris 2007). One study analysed singleton live births and stillbirths for 1980–2001, to understand the relationship between the effects of young motherhood on Māori birth outcomes, the prevalence of small babies (both preterm and small for gestational age, SGA) and the influence of economic deprivation on obstetric parameters (Mantell et al 2004). The study found that the younger age of Māori women does not appear to have an impact on their reproductive outcomes, but there are few initiatives aimed at reducing the impact of motherhood on their education and social development. The study also confirmed the significance of antenatal support with greater focus on wider health and social needs of Māori women, because ‘the sensitivity of Māori SGA rates to socioeconomic deprivation suggests that broader social and policy interventions are needed’ (Mantell et al 2004, p 540).

Contributing factors to Māori health status

Education

Māori have lower levels of educational achievement when compared with non-Māori (Te Tāhuhu o te Mātauranga/Ministry of Education 2007). They are more likely to be suspended from school, but specific initiatives targeting Māori young people have seen a reduction in overall suspension rates for Māori by 11% from 2001 to 2006.

Māori are more likely to leave the education system without university entrance qualifications compared with their non-Māori peers (Te Tāhuhu o te Mātauranga/Ministry of Education 2007). However, the percentage of Māori school leavers with a university entrance qualification doubled between 2001 and 2006, from 7.4% to 14.8%. The proportion of Māori school leavers who go directly to tertiary study from school has remained constant since 2001, increasing by only 1% to 51% of Māori school leavers in 2005 (Te Tāhuhu o te Mātauranga/Ministry of Education 2007).

Māori language education is embedded in a 25-year vision for the Ministry of Education, and the education focus for Māori overall is aimed at areas which are proven to transform the performance of the education system for and with Māori (Te Tāhuhu o te Mātauranga/Ministry of Education 2009). Priority areas include the first years of secondary school, Years 9 and 10, and Māori language education in English and Māori educational mediums. The Ministry of Education has active partnerships and relationships with 20 iwi (Māori tribal groups) and agreements with four national Māori education organisations (Te Tāhuhu o te Mātauranga/Ministry of Education 2009).

Income and living standards

Māori unemployment is higher than in any other ethnic group and living standards of Māori, on average, are lower than those of other New Zealanders (Centre for Social Research and Evaluation, Ministry of Social Development 2006).

The income of Māori overall is lower than for non-Māori with similar qualifications (Te Tāhuhu o te Mātauranga/Ministry of Education 2007). Māori who are employed have comparable living standards to other people who are employed (Centre for Social Research and Evaluation, Ministry of Social Development 2006).

Evidence suggests that Māori face discrimination in the labour market by consistently being segregated into lower-paid-occupation classes even after taking into account age and qualification differentials between Māori and non-Māori (Sutherland & Alexander 2002). Employment has an important bearing on financial capacity and self-esteem, as well as access to a range of opportunities, all of which contribute positively to health.

Justice

Māori offenders as a group tend on average to be younger than Europeans. Māori have a higher rate of re-imprisonment (55%) compared with New Zealand Europeans (45%) and Pacific Islander offenders (36%). Re-imprisonment therefore contributes to the disproportionate number of Māori in prison, which masks the true unemployment rate for Māori men (Nadesu 2008). Māori youth are more likely to come to the attention of the youth justice system and, although they present on average with less-severe offences, they are more frequently referred by the police to the Youth Court for minor offences rather than directly for Family Group Conference where outcomes avoid a criminal record. Youth Court outcomes are generally more severe than those of Family Group Conference, and this will have a corresponding impact on the rates of conviction, imprisonment and potential employment or education opportunities (Maxwell et al 2004). Māori offenders are more likely to come to police attention than non-Māori offenders with the same self-reported history of offending and social background. They are at greater risk of being convicted when they appear before the courts because of discriminatory processes, including bias in police arrest practice and cultural biases within the justice system (Fergusson et al 2003).

Such justice outcomes for Māori men have a corresponding impact on their partners and children, because women will carry the burden of ongoing childcare and household maintenance alone. Furthermore, Māori women in particular are at greatest risk of being a victim of a crime than any other group. This is because they are more likely than any other group to fit the profile of being at greatest risk of crime, such as living in a household where they are the sole parent, being unemployed or receiving a government benefit, and/or living in rented property and/or in the most deprived areas (Mayhew & Reilly 2007).

Mental health

Research into postnatal depression shows that many of the factors that place Māori women at highest risk of being a victim of crime also predispose them to postnatal depression more than other women (Webster et al 1994).

Māori in general are more likely to experience mood disorders, substance use and eating disorders than other ethnic groups (Baxter et al 2006). The prevalence of bipolar disorder is higher for Māori (3.4%) compared with Pacific people (2.7%) and others (1.9%) (Oakley Brown et al 2006

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