Birth by emergency caesarean delivery: Perspectives of Wāhine Māori in Aotearoa New Zealand

Abstract

In Aotearoa New Zealand, wāhine Māori (Māori women) are overrepresented in several negative post-natal outcomes, including negative outcomes related to caesarean deliveries. We aimed to understand the experiences of wāhine Māori who had experienced a caesarean delivery and to identify how healthcare systems can better meet the needs of wāhine Māori during pre- and post-natal care. Using kaupapa Māori principles, thematic analysis of one-on-one interviews identified eight themes covering a range of issues related to overall wellbeing. Bodily autonomy and choice were discussed by all participants, as was the need for mental wellbeing to be a larger focus of perinatal care. Participants also shared positive encounters with midwives and nurses, as well as a desire to incorporate religious and cultural practices within perinatal care. The caesarean delivery birthing stories of wāhine Māori highlighted the importance of Māori health models in understanding and providing culturally-affirming healthcare to wāhine Māori across Aotearoa.

The post-natal period can be challenging, with many physical and psychological changes that can affect wellbeing (Rowlands and Redshaw, 2012). Several factors influence the likelihood of negative post-natal outcomes (Leigh and Milgrom, 2008); including mode of delivery, which can play an important role in a woman’s recovery both physically and psychologically. However, there are other individual and social factors that must be considered regarding women’s wellbeing (Rowlands and Redshaw, 2012). In Aotearoa (New Zealand), understanding the birthing experiences of Māori, the indigenous people of New Zealand, and the care they receive following birth is important to ensuring equitable health outcomes. This study illuminates the experiences of wāhine Māori (Māori women) to identify how caesarean births can be a culturally-affirming practice within current healthcare systems.

Over the past decade the number of caesarean births has increased, accounting for around one-third of all births in Aotearoa across all ethnic groups and 22.89% of births for wāhine Māori (Te Whatu Ora, 2022). There is evidence that women who give birth by caesarean delivery are at increased risk of post-natal depression (Ogbo et al., 2018), anxiety (Field, 2018) and post-traumatic stress disorder (Bodin et al., 2022). These negative maternal mental health outcomes are associated with decreased physical and psychological wellbeing for mothers, babies and their families, and increased rates of maternal mortality through suicide (Field, 2018). One factor that predicts negative mental health outcomes for women following caesarean delivery is that the mother considers their birth experience to have been negative (Lewis et al., 2016). Perceptions of caesarean delivery may differ due to circumstances of the birth (e.g. elective vs emergency). Other factors such as women feeling that they were fully informed about the procedure, that aspects of their birth plan were incorporated, and that they had choice regarding their medical care increased the chance of a positive birth experience (Nielsen, 2019; Rodríguez-Almagro et al., 2019). There is further evidence that marginalised groups (e.g. Indigenous peoples and those from low socioeconomic communities) are more likely to experience negative outcomes following caesarean delivery (Ogbo et al., 2018). Furthermore, research on childbirth in Indigenous communities is important due to the higher prevalence of negative health outcomes such as preterm birth, low birth weight and higher rates of maternal and infant mortality in these populations (Adcock et al., 2021; Blakely et al., 2007; Smylie et al., 2010).

Indigenous populations have unique intersecting experiences within historical, social and political contexts (Smylie and Firestone, 2016). Interrelated determinants of health which explain the disparate health outcomes of Indigenous peoples include socioeconomic disadvantage, colonisation, marginalisation and racism (Durie, 2004; Smylie and Firestone, 2016). Colonisation had devastating effects on Indigenous communities throughout the world and has led to ongoing marginalisation and disparate outcomes for Indigenous peoples (Reid et al., 2019; Rumball-Smith, 2012). In Aotearoa, the tools of colonisation, including confiscation of land, ethnocide of te reo Māori (Māori language) and tikanga Māori (Māori practices), and criminalisation of tohunga (Māori healers), has had lasting effects that are still evidenced today by the ongoing healthcare disparities experienced by Māori (Dawson et al., 2019; Reid et al., 2019; Rumball-Smith, 2012). As colonisation has wide-reaching effects on all peoples (Kiddle, 2020), research on the experiences of marginalised and underprivileged communities is necessary to remove health inequities for all members of society.

The Crown has specific obligations to Māori under Te Tiriti o Waitangi (The Treaty of Waitangi); therefore, the healthcare system in Aotearoa has a responsibility to ensure equitable health and disability outcomes for Māori. One of the Ministry’s goals to uphold Te Tiriti includes Mana Motuhake – providing the right for Māori to practice self-determination and live according to Māori beliefs, values and practices within healthcare systems (Ministry of Health, 2020). Barnes et al. (2013) emphasise that wāhine have the right to culturally safe maternity care which honours individual values and choice. Approaches that may improve the health of Māori populations include reconnecting them with their cultural values and reclaiming important customs and traditions (Durie, 2004). This can be done by offering kaupapa Māori service provisions for example, by utilising models of health which have been developed to reflect Māori worldviews. These Māori models of health, such as Te Whare Tapa Whā (Durie, 2011), the Meihana Model (Pitama et al., 2007) and Te Pae Māhutonga (Durie, 1999), articulate how Māori worldviews can be more widely understood and applied to enable more holistic approaches to Māori healthcare. These models were developed from a Māori worldview, which promotes collectivism, interconnectedness and holism (Pitama et al., 2007). The application of Māori models of health allows Māori the space to practice self-determination within the healthcare system.

It is increasingly accepted that physical health alone is not a sufficient measure of wellbeing (Durie, 2011). Te Whare Tapa Whā espouses four dimensions which encompass a person’s overall wellbeing and provides a holistic view of one’s health. These dimensions, or pou (pillars), include: te taha tinana (the physical body and physical health), te taha hinengaro (mental health, including emotions and cognitions), te taha whānau (family relationships and belonging) and te taha wairua (the spiritual dimension, which includes a person’s connections to people, ancestors and their environment; Durie, 1994, 2011). Although they can be categorised individually, each dimension is dependent on one another and consideration for all is essential for total wellbeing (Pitama et al., 2007). Te Whare Tapa Whā has become embedded in Māori health policy and service providers should be more sensitive to addressing all four dimensions to provide culturally-affirming care for Māori.

Maternal mental health is as close to primary prevention as possible in the field of mental health (Bhat, 2017). Ensuring mothers have access to high quality culturally-affirming care during the perinatal period is essential for creating a safe environment for the mother and preventing negative outcomes for infants (Barnes et al., 2013). Thus, babies, partners, wider whānau members and communities all benefit from supporting mothers. Providing care which is culturally affirming is one way that health providers can empower women during the perinatal period. Maternal health, including mental health and wellness, contributes to the health of a pēpi (baby) during gestation and later development; for example, postnatal depression can impede processes such as parental-infant attachment (Barnes et al., 2013), which may result in a cascade of negative effects for the developing child (Lam et al., 2019), and maternal stress increases the risk of later development of internalising disorders such as depression and anxiety (Hoffman et al., 2017). Thus, empowering mothers through culturally-affirming birth practices may have ongoing impacts on her pēpi.

However, prior research has criticised health providers who consider the health of the mother to only be valuable to the extent that she impacts the health of her pēpi (Haas et al., 2005; Miller et al., 2016). Instead, care for the mother as well as her pēpi should be prioritised. There are several changes that women go through during the perinatal period (the period from conception until the first birthday of the pēpi), including physiological and psychological factors that contribute to a potentially challenging time for women (Haas et al., 2005). Suicide is the number one cause of death for pregnant and new mothers in Aotearoa, and Māori mothers are three times more likely to die by suicide than non-Māori, highlighting the necessity of better understanding the needs of Māori mothers (Perinatal and Maternal Mortality Review Committee, 2022; Walker, 2022). Therefore, there is a clear need for research to develop our understanding of the stories of wāhine Māori by listening to their lived experiences and using that knowledge to make changes that will contribute to increased positive experiences through the postnatal period.

In te ao Māori (the Māori world), birthing parents and pēpi are of utmost importance and are cared for and supported by communities (Walker, 2022). Traditionally, waiata (song), karakia (incantations), pūrakau (storytelling) and oriori (songs about the infant’s genealogy), were valued parts of maternal and neonatal care before, during and after birth. Māori birth customs include returning the whenua (placenta) to the earth after birth through a burial process. Pēpi are tapu (sacred) and are considered to be the closest a person can get to atua (deity; Walker, 2022). It would follow, therefore, that babies would be treasured, deeply loved and cared for by whānau and communities. However, colonisation undermined Māori beliefs and values, including customary birthing and parenting practices, leading to many Māori feeling disconnected from traditional practices (Le Grice and Braun, 2016).

The number of wāhine Māori giving birth by caesarean is rising in Aotearoa (Te Whatu Ora, 2022). To understand the impact of this increased medical intervention in birth, it is important to note that Māori are more likely to be exposed to risk factors like discrimination and marginalisation in the healthcare system (Ellison-Loschmann and Pearce, 2006). Additionally, mothers who require tertiary level care (i.e. a full range of hospital-level care, available at only six healthcare providers in Aotearoa New Zealand) may have to deliver far from their family, leaving them without whānau support. This is particularly consequential for Māori mothers given the socioeconomic marginalisation experienced by Māori. In Aotearoa’s healthcare system, wāhine Māori often experience worse treatment than non-Māori due to ongoing effects of colonisation, such as a non-representative healthcare workforce, systemic racism and socioeconomic determinants that disproportionately affect Māori (Reid et al., 2016; Rumball-Smith, 2012). Simmonds and Carlson (2022) argue that colonisation has systematically sought to dismantle traditional Māori birthing practices and attacked the knowledge wāhine Māori have surrounding the sanctity of birth and the maternal body.

Having the space to incorporate traditional Māori birthing practices can be culturally affirming for wāhine and their whānau (Adcock et al., 2021). By facilitating birth practices that are strongly grounded in their cultural values, healthcare providers can ensure the best birth outcomes for Māori mothers and their pēpi. The lives of both māmā and pēpi are vital in te ao Māori, so emergency/acute caesarean deliveries that are carried out to ensure the safety of māmā and pēpi can be a culturally safe procedure. Furthermore, birthing knowledge that is traditionally passed from generation to generation could include discussions of caesarean deliveries and how whānau have incorporated their cultural practices into those births. Waiata, karakia and naming and placenta rituals can also occur outside of or alongside the medical procedure (Adcock et al., 2021).

Wāhine Māori have historically been denied healthcare services that support their cultural values (Palmer, 2002). Until the health reforms in the 1990s, Māori did not have a choice in maternity care or birthing techniques, with Māori birthing practices including squatting or kneeling not allowed in hospitals (Wepa and Te Huia, 2006). Furthermore, for Māori, birthing in hospitals often meant prohibition of whānau support, separation from pēpi and lack of understanding of spiritual health by health professionals (Palmer, 2002). For wāhine Māori now, this may mean accepting medical advice without exploring all their options, or they may not feel empowered to ask for what they want. Health providers who acknowledge important cultural traditions and rituals help preserve cultural identity and enable feelings of safety and empowerment for wāhine Māori.

Understanding what constitutes culturally safe and culturally affirming birthing processes for wāhine Māori and their pēpi can guide practices that contribute to equitable birthing outcomes for women, babies and whānau. While birth-related procedures such as caesarean delivery may be medically essential, cultural practices could be better incorporated to ensure that the pēpi and mother are both medically and culturally safe. To our knowledge, there is little research exploring the experiences and decision-making processes of wāhine Māori who have had a caesarean delivery, or the effects on their overall wellbeing. In this study, we sought to contribute to the nascent body of research exploring culturally-appropriate birthing practices within hospital-level care settings (e.g. Adcock et al., 2021).

Wāhine Māori were asked to describe their experiences of giving birth by caesarean delivery. To honour women’s experiences, it was decided not to define what is or is not a negative birth experience. Participating mothers categorised for themselves aspects of their birth experience that met or did not meet their expectations. Negative experiences included (but were not limited to): negative post-natal physical and mental health outcomes, disappointment about birth experience, lack of cultural safety during birth experience and wider effects on the child or extended family. The aims of this study were to understand the experience of wāhine Māori during the process of caesarean delivery, to understand how the healthcare system is already supporting culturally-sensitive birthing practices, and to identify how healthcare systems can better meet the needs of Māori.

Method

Kaupapa Māori research

Smith’s (1997) work is part of a broader movement of Kaupapa Māori research which began in the education field (Smith et al., 2023). Smith’s (1997) description of Kaupapa Māori principles have been used widely to apply Kaupapa Māori values across research which assist Māori aspirations. Kaupapa Māori theory is a framework that is conducted by Māori, with Māori and for Māori (Smith, 1997) which utilises and affirms mātauranga Māori as being essential to understanding Māori world views (Pihama, 2001). Kaupapa Māori research includes practices which are relational, such as extending validation, listening before speaking, taking a collaborative approach, being self-aware of personal biases and displaying humility (Adcock et al., 2021). Thus, the research team engaged in mihimihi (greetings), whakawhanaungatanga (establishing connections), kaupapa (explaining the purpose of the interview), kai (food) and poroaki (closing the interview) throughout all interviews during the research period (Pitama et al., 2017). The researchers also used karakia (prayer) to open and close the space, as well reminding participants of confidentiality. Three authors of the present study are Māori.

Participants

This study was approved by the University of Otago Human Ethics Committee (H22/O78). The Ngāi Tahu Research Consultation Committee was also consulted. Wāhine Māori were recruited through the researchers’ networks. Three of the four participants were known to the interviewer. The sample included wāhine Māori, who had given birth via caesarean delivery. Once participants had indicated that they would like to find out more information about the study, they were given an information sheet electronically. Participants provided written informed consent. Participants were invited to be interviewed either online (Zoom) or at the University.

Four wāhine Māori ranging in age from 27 to 33 years participated in this study. Two wāhine experienced two caesarean deliveries and two wāhine had experienced one, all within the last 6 years. All participants had had a caesarean delivery in Aotearoa, and one participant had one of her two deliveries overseas. Each participant had between one and four children and participants lived across Aotearoa. One participant experienced the loss of their infant. All participants reported that their caesarean deliveries had been deemed an emergency by medical professionals.

Interviews

Two interviews were held in person and two were held over Zoom. Two authors (postgraduate students in clinical psychology) were present during the interviews. Kai (food) was shared at the interviews held in person, and karakia was offered at the beginning and end of each interview. Each interview started with introductions of those present, as well as a reminder about confidentiality. Participants were told that the first author had experienced a caesarean delivery. Participants were first asked to share their birthing story, after which the researcher followed the lead of the participant in what they wanted to share, as well as asking open-ended questions to learn more about their experiences. A full list of questions used to guide the interviews can be found in the supplementary materials. Semi-structured interviews were based on three topic areas: the participant’s birth story, the experiences surrounding the level of care they received before, during and following birth, including what the participant found positive and negative; and discussion around cultural practices that were used or that participants would have liked to have used during the labour and delivery process. Participants were invited to bring whānau or support people to the interview; however, none of the participants did.

Analysis

Thematic analysis using Braun and Clarke’s (2006) method was utilised to characterise themes discussed during the interviews. The initial transcription of the interviews was done using an automatic transcription software, Otter.ai (Liang and Fu, 2016). Any mistakes found in the automatic transcription were manually corrected, and then each transcript was re-read at least twice for familiarity with the data. Codes were assigned to corresponding extracts of transcript using coding software, NVivo (Version 1.6.1); the research team then gathered the coded extracts and grouped them together into broader categories that became eight preliminary themes. The transcripts were re-read to further refine the themes and either separate or combine them as needed, then each of the themes was given a label and definition. Data from the transcripts was explored with each theme in mind and further refinements were made to the key themes. All transcripts were anonymised to maintain confidentiality of the participants (participant codes are recorded after each quote). Non-meaningful verbosity was not included in the quotes in the results section; however, such omissions did not alter the meaning of each quote.

Results

The thematic analysis focused on how each participant made sense of their experiences of having a caesarean delivery, how they described their treatment during the prenatal and perinatal periods, as well as any thoughts they wanted to share with healthcare providers based on the experiences they had. After reflecting on the themes, we determined that the participants’ experiences could be well understood with reference to the Te Whare Tapa Whā model. Therefore, the themes and subthemes were organised under the framework of Te Whare Tapa Whā (see supplemental materials), the dimensions of which need to be considered together to fully understand and enhance Māori wellbeing. While the four dimensions were used to structure the discussion of themes, they are largely overlapping because they are interconnected in nature.

Te Taha Tinana

Te Taha Tinana encapsulates the bodily side of health (Durie, 2011) and considers how one’s body feels, how it is cared for and what an individual is doing to nourish their physical selves. Although a person may not always be in control of their physical state, it is important that they still have a sense of bodily autonomy and control over what is happening to them physically. In the present study, themes within this component of Te Whare Tapa Whā include the challenges of physical recovery after a caesarean delivery as well as how a biomedical approach to healthcare impacted participants’ care after birth.

Theme 1: Bodily autonomy

The first theme which was evident across the interviews was the challenges that the participants had when it came to their bodily autonomy and feeling in control of the choices that they were able to make. This theme also includes discussion on why participants may have felt like they could not stand up for themselves, or felt they had to suppress their own physical needs.

Subtheme 1.1: Feeling as though choices were taken away

Some participants felt as though they were not in control of their birthing experiences due to their perceived lack of choice. In many cases, participants felt as though having a caesarean delivery was presented as the only option for them, leaving them feeling out of control.

And if I like I said before, if I had been given a choice I don’t know if I would have tried to have the natural one. But at least I would have been able to have an option. (P1)

I felt like once I was starting to get induced, decisions were taken away from me. (P4)

Subtheme 1.2: Not being able to set physical boundaries

Another subtheme was how participants felt as though they were unable to stand up for themselves or did not feel comfortable enough to set boundaries and say what they wanted or needed. Many participants discussed thinking that asking for alternatives would result in lower quality care or that resistance to the health professionals’ recommendations would disadvantage them in some way.

Yeah so anyway, she booked me in for an induction, which I didn’t want, I knew that my baby was not ready, I knew that I was not ready. I didn’t know that I could say no and I was worried that if I said no, I wouldn’t have anyone to care for me during my labour and delivery. (P3)

Theme 2: A focus on physical health at the expense of other areas of wellbeing

A second theme related to Te Taha Tinana was participants perceiving a greater focus on physical health, with other areas of wellbeing neglected. Wāhine Māori expressed that postnatal check-ups were centred on physical aspects of recovery, including checking the caesarean wound, and psychological health was not a focus.

And so I don’t have the nurse, I don’t have anyone asking me how I am? They are asking me how my scar is. What’s your discharge? Like, you know, are you still bleeding a lot? (P3)

Yeah, I think mental health needs to be so much more at the forefront. That seems to be way down the list of things that are being checked on or looked at. (P3)

For one participant, the combination of the hospital setting and the fast-paced manner of the doctors and nurses made her feel as though she was just on a roster of physical care, and that other areas of her wellbeing were not considered.

And when we reflected on it later, what it was is that the combination of a really long long labour, not a very enjoyable experience of hospital care as well, like the combination of the long labour, not a great midwife experience, the c-section where I didn’t really remember it and then the days in hospital, just feeling like our privacy and our space was constantly intruded on like a roster of tickboxing care, like, yeah, it took a really long time to feel like I was his mum and he was my baby and I could care for him. (P2)

Te Taha Whānau

Te Taha Whānau encompasses an individual’s sense of belonging, those people who make the individual feel like they belong, and who they are connected with. This does not only include immediate or biological family members, but rather family in a Māori sense which includes extended kinship (Durie, 2011). This includes friends, community and those the individual values and gathers strength from. The importance of family has implications on health, for example, knowing where one comes from determines one’s role within one’s whānau and contributes to one’s sense of identity. In the context of the birthing experiences described by the participants, whānau is used to describe the social support the participant had or wanted to have, including family members.

Theme 3: The importance of whānau support

Across all participants, it was evident that having whānau support during the pregnancy, labour and following birth was beneficial. The support of partners was especially important as they could act as advocates for the wāhine Māori, expressing her desires if she did not feel she was able to.

My husband totally went through the labour with me. I know that somebody will say, oh, my husband slept for blah, blah, blah, or you know, this or that. No, my husband was holding me the entire labour. (P3)

But my husband is probably the most, probably the most calm kind of, in situations like that he doesn’t look like, he’s just calm. So, he made me feel calm. (P1)

Theme 4: Lack of support and assumptions around support

Another important aspect surrounding the support that comes from whānau is the assumption that everyone has people to help them or take care of them once out of the hospital setting. However, this is not always the case, and one participant expressed how difficult this made her post-natal recovery.

I think people assume; well I don’t know if they assume, but the way that our culture is here. Our families are here. I think there’s an assumption, oh you have someone that you know, this kind of assumption that everyone just sort of has a little base or support network or whatever, but it’s not the case for everyone. (P3)

Te Taha Hinengaro

Te Taha Hinengaro considers the psychological dimension of health (Durie, 2011). An individual’s thoughts, feelings, conscience, mind and heart are all important aspects of one’s health. This realm considers how a person communicates, thinks and feels, as well as how they respond in certain situations. In the context of birthing experiences, hinengaro represented the mental and emotional wellbeing of the participants, how well-cared for they felt during their labour and delivery process, as well as ongoing trauma related to birth.

Theme 5: How midwives and support staff contributed to a positive birth experience

The participants expressed that several support staff, including midwives and nurses, contributed to a positive experience during their labour and following birth. Most of the positive experiences were centred around healthcare professionals who ‘went the extra mile’ or showed they saw the wāhine Māori as more than just a patient, but as a person who needed care.

Whereas [midwife 2] was doing that, but above that, I just felt like she was a little bit more like invested and she was a little bit more like, actually cared. (P1)

I remember this beautiful Indian midwife came in and it was the first person that actually came over to me properly and said, how are you? And I said, and I remember crying and just being like I just need a hair tie, can you get me a hair tie? (P2)

And, and being in a hospital situation, in a hospital environment, sorry. I felt like a number. Everyone’s rushed, you know, everyone seems to be rushed. People you don’t know, people are checking your, your tags because they don’t know what your name is, you know, things like that. So, to have had that midwife that she understood what I wanted. She helped me try and get what I wanted. And staying longer than she had to? I knew that she did that for me. Yeah. And it was nice to have someone do something for you. Instead of for them. (P3)

Theme 6: The ongoing trauma associated with an unexpected birthing experience

For all participants, the unexpected nature of their birth via caesarean delivery impacted their psychological wellbeing. While this varied in severity across participants, all mentioned how difficult it was to come to terms with their births. This included the need for some wāhine Māori to participate in therapy and birth trauma counselling following the birth of their child. For others, this trauma was reflected in the way they described their caesarean delivery, feeling as though they were denied their ideal birthing experience.

It shouldn’t be that I had this experience that I needed so much therapy to digest. And constantly being asked how that experience was or how if I’m going to do it again, triggers me like it’s such a. . . yeah. (P2)

My first visit with my midwife, she asked me, can you tell me about your first birth. And when I started to tell her about my first birth, I just bawled my eyes out. And I was super upset about it. And I did not know that I felt that way about it. I didn’t know until I told someone. (P3)

Te Taha Wairua

Te Taha Wairua includes the values and beliefs that a person holds. While this dimension of health may include religious or spiritual beliefs and customs, it is much broader (Durie, 2011). Te Taha Wairua also considers the way an individual’s values influence how they live, what they focus on to find meaning in their lives, as well as their sense of personal identity and self-awareness. In the context of birthing experiences, wairua is used to describe how religious and cultural practices were used during birth, as well as how the participants perceived societal expectations around motherhood and how their sense of identity was impacted by having a caesarean delivery.

Theme 7: The effects of values being heard and listened to

For participants, it was evident that having their values and beliefs respected was an important part of cultivating a positive environment to give birth. Feeling in control of some aspects of the birth enabled participants to feel strong, to have confidence in their abilities and feel an overall sense of respect between themselves and the medical professionals.

Subtheme 7.1: Incorporation of religious and cultural practices

One participant in particular spoke about how her religious practices were honoured and that she was given the space to engage in certain rituals that helped bring her and her whānau comfort during a particularly challenging time.

And even with [child 2], like, because we’re in the NICU, and this is post birth, yeah and they were so, even when she passed away, they were really good with, do you want us to get someone in? Do you want? And I remember we gave, [husband’s name] wanted to give her a blessing and [brother-in-law’s name] was there, and my brother-in-law was there. And they were like, do you want us to stay, do you want us to leave, do you want us to? They were really respectful of that. And it was really nice. Yeah. That was a really good experience. (P1)

For some participants, important cultural rituals such as bringing home the whenua (placenta) were able to be fulfilled. However, one participant spoke of her desire for her birth to be aligned as much as possible with cultural practices, including wanting a water birth, having a muka tie (a flax fibre umbilical cord tie) and birthing her placenta as opposed to having it removed via medical methods. Unfortunately, she was unable to carry out these rituals in the way she would have liked.

Well I wanted to have her as culturally, to my culture, well our culture as much as I could. I wanted to try and keep the tikanga of it all. (P4)

Theme 8: Identity and hopes associated with being a mother

The final theme was the way that participants perceived motherhood to be, how they felt society expected labour and delivery to be, and how their identity was linked to their birthing experiences and the beginnings of their journey into motherhood. They expressed feeling as though they had to have certain emotions or show gratitude in a certain way, and that just being a mother or being alive with a healthy pēpi (baby) was all that mattered in the eyes of society.

I’d read lots of books about labour, my midwife had given me lots of information. And I think the narrative and all of the reading I’d done or like, I’d been listening to podcasts and all sorts of stuff. And the narrative was always that the c-section was a last resort, or like the c-section was bypassing what your body will do naturally on its own and I remember being like, well, okay, sure, my body will just do it. (P1)

Being a mum was all I ever wanted to do. And then when I actually had my child, it was nothing like I expected. So, I, I feel like I came into motherhood, like kind of on the backfoot, you’re supposed to be like, grateful that, that you’re safe, that you’re healthy, your baby’s healthy, that neither of you died. But like, that’s not enough. (P3)

And I was like, I was just sad, and I had no one to tell that I was sad. Because if someone doesn’t ask you how you are, it’s really hard to just say to someone that comes to visit you, hey, actually, I’m sad. You don’t want people to know that you’re sad, you just had a baby. It’s supposed to be the best thing you know. (P3)

Discussion

Although a range of experiences were shared, there were a number of recurrent themes that illuminated the importance of considering total wellbeing during the perinatal care of wāhine Māori. Eight themes were evident across the interviews as being important aspects of the birthing experience. These themes were conceptualised under the four dimensions of Te Whare Tapa Whā (Durie, 1994). Themes related to bodily autonomy, medical professionals’ focus on physical health at the expense of mental health, how family and healthcare workers can contribute to positive experiences, ongoing trauma associated with caesarean birth, the inclusion of cultural practices to enhance the birthing experience and societal pressures associated with birth and becoming a mother.

Te Whare Tapa Whā is an important framework to understand the multiple facets that contribute to overall wellbeing. Te Whare Tapa Whā is holistic in nature and recognises interacting dimensions of wellbeing that need to be considered together. This Māori model of health has also been usefully applied and adapted among other Indigenous peoples and non-Indigenous groups (Matapo-Kolisko, 2021). The results of our study support prior research suggesting the importance of all four dimensions of Te Whare Tapa Whā in promoting overall wellbeing (Durie, 2011). All participants touched on experiences they had physically, emotionally, socially and spiritually, which came together to either support or hinder their wellbeing. For participants, post-natal check-ups which focused on physical markers of health, such as wound recovery, were not enough to feel sufficiently supported. Comprehensive post-natal check-ups could include asking about whānau support, asking about mental health and discussions about how wāhine felt their birth experience went or how they were managing expectations of being a mother, would be extremely beneficial.

For many participants, they felt as though they were unable to voice their desires and speak up for what they wanted or needed during birth. For several decades, wāhine Māori were unable to birth in certain places or in certain traditional birth positions (e.g. squatting), in hospitals across Aotearoa (Palmer, 2002). Historical bans on traditional Māori practices may have led to wāhine Māori in the present day not feeling empowered to express their needs in hospital settings. The participants expressed apprehension about articulating their desires to healthcare providers; for one participant, they felt as though an expression of needs would be met with a reduction in the quality of care they would receive from medical professionals. This may be related to fear that pushback may result in one becoming the problem rather than the victim due to racial bias and stereotyping (Jones and Norwood, 2017). For others, the fast-paced environment of the hospital and feeling like a ‘number’ on a rotation of care meant that they were uncomfortable asking for help unless it was offered. Participants identified that healthcare professionals who took the time to connect with them, and who showed professionalism in their practice as culturally competent and safe practitioners, were vitally important to their birthing experience.

Consistent with previous research (Nielsen, 2019; Rodríguez-Almagro et al., 2019), participants expressed several factors which contributed to a negative birth experience which went beyond having a caesarean birth itself. Wāhine Māori shared how disappointing it was feeling as though they were not fully informed about obstetric procedures such as induction or caesarean delivery. Furthermore, they expressed dismay regarding their inability to experience the type of birth they had planned for, as well as feeling as though they had no choice but to follow medical professionals’ advice. Overall, these experiences contributed to negative perceptions of the birthing experience. This is consistent with previous research which suggests that choice plays an essential role in whether the birthing person has a positive or negative experience. Although caesarean delivery may be medically necessary in some situations, patient agency can be maintained by including the wāhine and whānau in the decision-making process, that is, clearly explaining why the medical procedure is advisable and ensuring the wāhine understands potential risks and outcomes.

Research has suggested that it may not be caesarean delivery itself that mediates negative post-natal outcomes, but whether the birthing person considers their birth to be negative (Lewis et al., 2016). Participants’ descriptions of their experiences included discussions around participation in therapy and trauma counselling following birth to help them come to terms with their birthing experience. Our results were consistent with previous research, as participants described how they believed their negative experiences contributed to a range of difficult experiences and emotional distress after birth.

Our findings highlighted how for many wāhine Māori the nature of their birth meant that they were unable to include some Māori birthing practices. However, there were some traditional practices they were able to include which contributed to a more positive birthing experience. For example, participants discussed being able to keep the whenua and engage in a traditional Māori placenta burial after birth which helped them feel empowered. Making these practices possible for wāhine Māori contributes to creating a birthing experience which is positive and culturally affirming. This could decrease the likelihood of wāhine Māori having negative birth experiences which may help address existing health inequities in Aotearoa (Berryman et al., 2022). Although the ability to engage in one traditional practice may not be sufficient for the wāhine Māori to deem the entire experience as being positive, including traditional practices where possible is necessary for culturally-affirming care.

One limitation of the current study was that half of the interviews were conducted online via Zoom, due to geographical barriers. For Māori, kanohi ki te kanohi (face-to-face) communication enables one to not only communicate verbally, but to also feel and sense the relationship (Whaanga et al., 2017). This enables a better sense of connection between the parties involved in the hui (meeting) and can reduce the risk of miscommunication, ensuring that the participant’s experience is understood correctly. Using Zoom as a means of communication did open the geographical boundaries of the study and allowed us to include participants outside Dunedin. However, future research may consider only conducting interviews kanohi ki te kanohi, to establish connections and create a physical space wherein the participant feels safe to share their experiences.

The current study adds to the literature on birthing experiences by focusing on wāhine Māori and the unique challenges they face. The findings of the study imply that for wāhine Māori, the impact associated with giving birth via caesarean delivery affects all areas of wellbeing. Māori models of health such as Te Whare Tapa Whā are important means by which service delivery can be tailored to Māori. The results imply that culturally-affirming care that provides information to enable wāhine and their whānau to make informed choices, honours women’s values and beliefs, and addresses physical, emotional, social and spiritual wellbeing in a holistic way, is likely to be more effective and result in positive birthing experiences.

Furthermore, the lived experiences which were shared in this study are valuable and can directly inform the policies and practices which healthcare professionals implement in their healthcare services. For example, including routine mental health check-ups as often as physical health check-ups could provide wāhine Māori the opportunity to share concerns regarding emotional challenges that may be occurring following birth. Another example would be to provide wāhine Māori with as much space as possible to perform spiritual and cultural rituals and practices throughout the labour and delivery process. In future studies, researchers could continue to interview wāhine Māori to hear about their experiences within primary healthcare, as there is much more that needs to be understood from their lived experiences. Future research which continues to explore how services can provide culturally safe and affirming care across Aotearoa is vital to reducing the health inequities currently experienced by Māori throughout the country.

The findings from this research highlight that wāhine Māori valued the opportunity to be included in the medical decision-making process and to feel supported in the choices they made regarding birthing options. Furthermore, they benefitted from whānau support, including immediate whānau who were able to advocate to medical professionals on their behalf. Finally, having the space to implement important rituals, be it religious practices or traditional Māori practices, was highly beneficial for wāhine Māori, helping them feel empowered and in control during a time when it was easy to feel out of control. To our knowledge, this is the first study to explore the unique experiences of Māori who have had caesarean deliveries. Further, the current study adds to the scarce literature on Māori within maternal health settings. Making sure all areas of wellbeing are cared for during the prenatal and perinatal periods may improve the experiences of wāhine Māori and lead to an overall more positive birthing experience, potentially improving post-natal health and wellbeing.

Supplemental Material

sj-docx-1-hpq-10.1177_13591053231218667 – Supplemental material for Birth by emergency caesarean delivery: Perspectives of Wāhine Māori in Aotearoa New Zealand

Supplemental material, sj-docx-1-hpq-10.1177_13591053231218667 for Birth by emergency caesarean delivery: Perspectives of Wāhine Māori in Aotearoa New Zealand by Felicia Airini Lawrie, Yvonne Awhina Mitchell, Ashleigh Barrett-Young and Amanda Ellen Clifford in Journal of Health Psychology