“Thank you for Listening” Kaupapa Māori Methodology as a Facilitator of Culturally Safe Research With Māori Mothers Experiencing Perinatal Mental Illness

Abstract

Māori are the Indigenous peoples of Aotearoa, New Zealand, and, similar to other Indigenous populations, face significant health inequities. Of concern, Māori mothers and birthing parents experience persistent and grave mental health inequities within the perinatal period relative to other ethnic groups. Indigenous research participants who have mental illness and who are also pregnant or in the early stages of parenting present intersecting ethical dilemmas for researchers working with research participants in situations of vulnerability. Given the known historical harms that culturally unsafe research has previously caused Indigenous peoples, it is crucial that research approaches with Indigenous mothers and birthing parents who have experienced mental illness are culturally safe and ethically sound. Kaupapa Māori research provides a framework to decolonise research processes and create the conditions for the cultural safety of the researcher and research participants. Kaupapa Māori research is grounded in a philosophy of relationship and a mutual recognition of the mana (dignity, prestige) of both researcher and participant. Engaging in culturally safe and responsive research with Māori can address power imbalances and ensure that the priorities of Māori communities are centred within the research. This paper details the application of a Kaupapa Māori research methodology used within qualitative research with Māori mothers and birthing parents experiencing perinatal mental illness and is structured in three parts. The first section situates Kaupapa Māori methodology in relation to the context of Māori mothers and birthing parents experiencing perinatal mental illness, providing a rationale for the research. The second section describes the application of Kaupapa Māori methodology within the research project. The third section discusses Kaupapa Māori methodology’s influence on research participants’ cultural safety through a case study format.

Keywords

cultural safety perinatal mental illness Māori mothers kaupapa Māori mana wāhine

Introduction

Māori are the Indigenous peoples of Aotearoa, New Zealand (NZ), and are connected through whakapapa (genealogy) to iwi (tribal groups), hapū (sub-tribes), and whānau (family/support networks). Parallel to Indigenous groups globally, Māori face significant health inequities due to the ongoing impacts of colonisation (Kewene et al., 2023). Colonisation included land theft, which has caused ongoing negative consequences such as intergenerational poverty, while other impacts such as language loss, systemic racism, and the creation of structural barriers preventing equitable access to the social determinants of health (Kidd et al., 2022; Sheridan et al., 2024), all contribute to significant trauma and mental illness (Maree Kopua, Kopua, & Bracken, 2020). In Aotearoa, NZ, Māori mothers, and birthing parents experience significant and grave mental health inequities within the perinatal period relative to other ethnic groups (PMMRC, 2024).

Known contributors to health inequities are the poor experiences Māori face within the health system and within clinical interactions. These experiences relate to structural and systemic racism embedded within a health system designed to privilege non-Māori and exacerbated by culturally unsafe and harmful clinical interactions (Graham & Masters-Awatere, 2020; Palmer et al., 2019). In response to rising concerns about inequitable health outcomes and cultural harm experienced by Māori, the concept of cultural safety was developed by Māori nurses in Aotearoa, NZ (Ramsden, 2002). Cultural safety addresses quality in healthcare through supporting clinicians to engage with Māori patients in ways that do not diminish, demean, or disempower cultural identity (Papps & Ramsden, 1996).

Research on populations experiencing significant health burdens has been prolific as health researchers attempt to improve health interventions and understand the lived experiences of such groups (Wilson & Neville, 2009). For Indigenous peoples, the nature of such research has frequently caused further harm (Smith, 2002). This harm has resulted from culturally unsafe and unethical research approaches and from the privileging of Western knowledge systems and non-Indigenous ways of understanding (Smith, 2002; Wilson & Neville, 2009; Wright et al., 2019). These harmful and often long-lasting impacts of health research have exploited Indigenous peoples, perpetuated inequities, and failed to critically appraise the systemic and structural causes of health inequities, instead leading to a deficit framing of Indigenous realities (Huria et al., 2019). Concerningly, existing research that includes Indigenous cohorts rarely distinguishes if the research aims have emerged from priorities identified by Indigenous communities that have arisen either from empirical evidence and/or concerns outlined by the Indigenous communities themselves (Huria et al., 2019). Congruent with these concerns, there has been minimal research designed to further knowledge and understanding of the experiences of Māori with perinatal mental illness, despite quality mental health research for Indigenous populations being a global priority (Haitana et al., 2020).

Indigenous research participants who have mental illness and who are also pregnant or in the early stages of parenting present intersecting ethical dilemmas for researchers concerned with issues around the ‘vulnerability’ of research participants (de Wet et al., 2023; Lajoie et al., 2020). Despite the intention of Western research ethical frameworks to protect research participants, Indigenous communities have been continuously harmed by Western research practices. While notions of ‘vulnerability’ can support a critique of inequity and its causes (Marino & Faas, 2020), there have also been criticisms around the discourse of ‘vulnerability’ within health research. For instance, labelling Indigenous peoples as ‘vulnerable’ is inherently culturally unsafe as it obscures the power structures and systemic issues that create the inequities that expose certain groups to vulnerable situations (Chung, 2021; Katz et al., 2019; McLaren et al., 2020). Furthermore, it is argued that assigning labels of ‘vulnerability’ to Indigenous communities situates them as passive, powerless, or deficient and needing to be ‘saved’ by the West (Marino & Faas, 2020). When systemic and structural causes are obscured within research, attention is also focused on ‘downstream’ interventions and solutions, as opposed to the dismantling of the power structures that cause inequities (McLaren et al., 2020).

In contrast, decolonising, Indigenous research methodologies support researchers to be culturally safe through ensuring that they have a critical lens on ‘vulnerability’, consider issues such as colonisation, racism, and economic exploitation, avoid a deficit focus, and highlight the strengths of Indigenous communities (Katz et al., 2019; McLaren et al., 2020). Kaupapa Māori research methodologies arose in part due to the harmful impact of deficit-based Western research methodologies on Māori communities (Jones et al., 2006; Stevenson, 2018). As with other Indigenous methodologies, Kaupapa Māori research provides a framework to decolonise the research process and creates the conditions for the cultural safety of both the researcher and research participants (Cram, 2001). As such, Kaupapa Māori research has offered a significant contribution to positive and safe research processes and health outcomes for Māori (Haitana et al., 2020). Kaupapa Māori research methodology works to deconstruct the power structures that perpetuate inequities and oppression of Māori, aligning with aspects of critical theory and its ideas around critique, resistance, struggle, and emancipation (Eketone, 2008; Smith, 2002). Given the historical harms research has caused for Indigenous peoples, it is crucial that research approaches with Indigenous mothers and birthing parents who have experienced mental illness are culturally safe and ethically sound.

The overall research study aim from which this paper was developed was to understand the lived realities and experiences of Māori mothers and birthing parents accessing services for perinatal mental illness, identify the key enablers of access to perinatal mental health support and treatment, and to explore the priorities of Māori whānau in relation to perinatal mental health. This paper will detail how the research study was designed to create cultural safety for the research participants through the utilisation of Kaupapa Māori methodology. The design ensured that the aspirations, perspectives, and ideas of Māori parents were centred and highlighted throughout the research process. This paper will also describe how the approach ensured that the solutions offered by participants were outlined in a strengths-based framework to provide a roadmap towards equitable perinatal mental health outcomes.

This paper is structured in three parts. The first section will situate Kaupapa Māori methodology and Mana Wāhine theory in relation to the context of Māori mothers and birthing parents experiencing perinatal mental distress, thus providing a rationale for the research. The second section will describe the application of Kaupapa Māori methodology within the research project. Finally, the third section will discuss the influence of Kaupapa Māori methodology on the cultural safety of the researcher and research participants through a case study format.

Part 1: Research Rationale

Research Context: Māori Perinatal Mental Health

Several recent health reports have highlighted the urgent need for research into perinatal mental health outcomes for Māori (PMMRC, 2022, 2024; Walker, 2022). Māori experience higher rates of mental illness along with significant life stressors and exposure to risk factors within the perinatal period compared to the NZ European population (Becares & Atatoa-Carr, 2016; Thayer et al., 2019, 2023). Suicide is the leading cause of maternal death in Aotearoa, NZ, and this is especially prevalent amongst Māori compared to non-Māori (PMMRC, 2024). Despite these high rates of maternal suicide, data from Aotearoa, NZ, suggests that less than 50% of women who experience more than two weeks of low mood during pregnancy access help, with non-Māori women more likely to access help than Māori (Signal et al., 2017). Data also highlights how Māori experience racial discrimination within healthcare (Becares & Atatoa-Carr, 2016; Graham & Masters-Awatere, 2020). Longstanding racism and marginalisation in the healthcare system has direct consequences on maternal and infant mental health (Thayer et al., 2019, 2023). For instance, Māori who experience discrimination from a health professional are 66% more likely to suffer postnatal depression due to higher levels of maternal stress (Becares & Atatoa-Carr, 2016).

Increasing our understanding of perinatal mental illness and effective interventions is not only intuitive and important, but evidence demonstrates that effective interventions lead to better outcomes for mothers, birthing parents, and their children and are more cost-effective for the health system (Smylie et al., 2016). For example, perinatal mental illness affects the short and long-term health and well-being of infants in multiple ways (Sandoz et al., 2019; van Bakel & Riksen-Walraven, 2004), including low birth weight, breastfeeding difficulties, and neurodevelopmental disruptions and related challenges (Goodman, 2019; Stein et al., 2014). For the birthing parent, mental illness can contribute to poorer perinatal health outcomes and consequent obstetric complications, impacting postnatal recovery (Goodman, 2019). The outcomes for, and impact of, unmet need in Māori perinatal and infant mental health are evident in the health and social inequities that clearly highlight how non-Māori families are privileged within the perinatal mental health system. The evidence demonstrating the privileging of non-Māori families includes the well-established and grave inequities seen within state mandated placements for children, criminal justice settings, and children experiencing challenges with emotion regulation and behavioural disorders as a consequence of neurodevelopmental disorders associated with infants of parents with perinatal mental illness (Glover, 2020; Howard & Khalifeh, 2020; Penehira & Doherty, 2013).

Research Context: Kaupapa Māori Research in the Perinatal Period

Indigenous research has supported transformative change and equitable health outcomes and informed the design of high-quality and culturally safe mental health services (Haitana et al., 2020) and perinatal services for Indigenous mothers and birthing people (Adcock et al., 2021; Chamberlain et al., 2019; Hickey et al., 2021; Te Huia et al., 2023). Embedded within Kaupapa Māori research methodology are Māori worldviews with the cultural and ethical values that facilitate safe research practices with Māori (Reweti, 2022). These values include manaakitanga (hospitality, kindness, caring for), respect, and addressing power imbalances between participants and researchers (Stevenson, 2018). The overall aim of Kaupapa Māori research is to undertake Māori-led research that upholds the mana (dignity, prestige) of Māori communities and create transformational change for Māori wellbeing (Smith, 2012).

Mana Wāhine¹ theory is an extension of Kaupapa Māori theory and explores the intersectionality of being both Māori and a Māori woman (Simmonds, 2011). Mana Wāhine theory has been employed by key Māori researchers (Irwin, 1992; Murphy, 2013; Pihama, 2001; Simmonds, 2011; Yates-Smith, 2019) for decades and is grounded in the understanding that all Māori women have an inherent power and autonomy (Graham, 2018). Mana Wāhine provides a space where wāhine Māori are self-determining and empowered to define and tell their stories of their experiences (Simmonds, 2011). Mana Wāhine approaches operate in direct contrast to how, since the beginning of colonisation, Māori have had their stories and experiences defined by non-Māori and interpreted and told through an often white, male lens, leading to the diminishing or even erasure of Māori women’s voices (Yates-Smith, 2019). As such, Mana Wāhine theory provides a framework for researchers to ensure that the voices of Māori are centred and privileged within research, as opposed to being othered or diminished in relation to non-Māori voices (Graham, 2018).

Given the current inequities in perinatal mental health and concerns around research practices with Māori, it was essential, (in view of the study aims), that Kaupapa Māori research methodology was utilised within our research project. Furthermore, a recent scoping review explored the utilisation of Indigenous methodologies within perinatal health research and found that less than 2% of articles described or reported the use of Indigenous research principles, highlighting significant gaps within existing Indigenous perinatal health research (Patterson et al., 2022). These findings were echoed within a recent systematic literature review exploring Indigenous approaches to perinatal mental health (Meredith et al., 2023). Those methodological omissions were concerning, given the level of unmet health need for Indigenous mothers and birthing parents and the known harms that have occurred because of culturally unsafe research practices.

The intention of utilising Kaupapa Māori research methodology with Māori mothers and birthing parents was to centre and privilege their voices and harness their expertise to inform the health system on the priorities and approaches fundamental to addressing mental health inequities within the perinatal period. Kaupapa Māori methodology and Mana Wāhine theory underpinned this research and provided a framework so that all research processes were critically reviewed to ensure they supported the research aim, informed how the research was designed, conducted, analysed and reported, therefore guiding all research processes and considerations. These are described in detail in the next section.

Part 2: The Application of Kaupapa Māori Research Methodology with Māori Mothers and Birthing Parents

Researcher Positioning

The research team comprised the lead researcher (CM), a Māori midwife undertaking her PhD in Māori health with a focus on perinatal mental health. The three co-authors (TH, CMc, and SP) are all wāhine Māori researchers with expertise in Kaupapa Māori research methodology, Māori health research, and mental health research. CM had established relationships with two community perinatal mental health providers who supported the aims of the research and assisted with the recruitment process. This positioning supported the research process in two ways: firstly, CM’s experience as a midwife, connections to the community, and her positioning as a Māori researcher guided and supported by a strong Māori supervisory team enabled participants to trust the research process. Secondly, utilising Kaupapa Māori research methodology (described later in this section) facilitated culturally safe research practices. Consequently, participants offered detailed and open accounts of their experiences with mental illness and shared expert perspectives and solutions to improve the health system and address perinatal mental health inequities.

Ethics

The research project received ethical approval from the Health and Disability Ethics Committee of New Zealand (ID: 13768), and locality authorisations were granted by the two sites where interviews were undertaken. The CONSIDER statement (Huria et al., 2019) guided the planning, design, and reporting of the research. This is discussed in more detail later within this section. Ethical considerations are also further discussed in the third section of this paper.

Indigenous Research Reporting Guidelines

The CONSIDER statement, developed from Kaupapa Māori research principles and other Indigenous research frameworks, addresses the need for researchers to employ culturally safe methodologies when conducting research alongside Indigenous communities (Huria et al., 2019). It consists of eight domains researchers must address to ensure transparency in social accountability and cultural safety within their work. The following section will present the seven relevant domains and discuss their application to the research.

• Domain one - Governance: This research was funded by the Health Research Council of New Zealand through a Māori Clinical Research Training Fellowship. As such, the research design and proposal were peer-reviewed by Māori health experts and endorsed and approved for funding prior to the commencement of the research. Consultation and discussion were held with Māori clinicians and Māori managers at the two community interview sites before recruitment. A harm minimisation protocol was outlined within the ethics approval. The lead researcher for this study was a Māori midwife and PhD candidate supported by an exclusively Māori supervisory team.

• Domain two – Research Prioritisation: This study arose from the community priorities identified within a Kaupapa Māori health organisation delivering health and social services to Māori in the perinatal period. It was informed by a systematic literature review completed during the study period (Meredith et al., 2023).

• Domain three – Research Relationships: Research approaches followed Māori ethical guidelines, and the research team were all Māori researchers. The supervisory team have expertise in Kaupapa Māori and Indigenous research methodologies. The analysis was exclusively conducted by the Māori research team.

• Domain four – Research Methodologies and Methods: This paper discusses in detail this study’s methodological approaches and analysis.

• Domain five – Research Participation: This research was a qualitative study with no biological samples collected. Given that participants were parents of young children they were offered their choice of time and place for conducting the interviews to allow for flexibility and minimise the demands on their time and resources. Participation was voluntary, with no pressure placed to take part in the interviews. As discussed later in this paper, tikanga guided participation in the interview process. Interview transcripts were de-identified and securely stored on the University network, where they will be held for ten years.

• Domain six – Research Capacity: This research contributed to the development of research capacity by providing employment, support, and training to a Māori research fellow and PhD candidacy.

• Domain seven – Research Analysis and Interpretation: This paper details the approaches to analysis and interpretation.

• Domain eight – Research Dissemination: A dissemination plan for the study was developed in consultation with key Māori stakeholders, including Māori midwives and the two service providers that were recruitment sites. Other dissemination plans included a lay summary to be developed with appropriate artwork and given to all participants; a commitment to publish in open access journals; presentations of study findings at the two community service providers to their clinical and support staff; and presentation of findings at relevant national and international conferences and community perinatal health and mental health organisations.

Semi-Structured Interviews

Semi-structured interviews were the chosen method of data collection. This method allowed the researchers to develop a set of guiding questions while also allowing the participants to have autonomy within the interview, choosing to skip questions or delve deeper into some areas of discussion if they wished. Ultimately, participants always had control of the conversation. The structure of the interview process incorporated features of the Hui Process (Pitama et al., 2017):

1. Mihimihi: this process involved initial greetings and introductions and included the sharing of whakapapa (genealogical links) and background.

2. Whakawhanaungatanga: the intention of this process is to build and understand shared connections.

3. Kaupapa: this involved a conversation to explain, clarify, and answer questions about the purpose of the interview. Consent forms were revisited and signed at this point. The semi-structured interview then followed. Interviews ranged from 90 minutes to 2 hours in duration. With consent, the interviews were audio recorded.

4. Poroaki: at the end of the interview, key points were summarised and clarified before finishing, with the offer of the space to address anything the whānau felt was important but had not been asked during the interview. An offer to provide a copy of the results once the research was completed was also discussed.

In acknowledgement of the sensitive nature of the interview topic, karakia (traditional blessing, incantation, prayer) were offered and recited prior to the interview being commenced to clear a path and guide the conversation spiritually. At the end of each interview session, another karakia was offered to close the conversation and ensure the spiritual safety of both the researcher and participants. All participants requested or accepted the offer of both opening and closing karakia. In alignment with tikanga, kai (food) was shared at completion of the interviews. A small koha (gift) was also offered to participants to acknowledge their time, energy, and expertise. This koha was in the form of grocery vouchers and a food basket.

Interview Questions

Within the current literature, most studies explore health professional and auxiliary staff perspectives of perinatal mental health, many of whom are non-Indigenous, with minimal data available on the perspectives of Indigenous mothers and birthing parents (Meredith et al., 2023). It was decided that for this research, only Māori mothers and birthing parents with lived experience of perinatal mental illness would be interviewed. Kaupapa Māori methodology supports this positioning of Māori voices, as experts, at the centre (Smith, 2002), ensuring that the research is meaningful and beneficial to the research participants and their communities. Open-ended interview questions were designed to capture experiences and perspectives and explore the barriers and enablers experienced within clinical settings and the health system.

Recruitment

Participants were recruited from two community organisations offering perinatal mental health services to Māori mothers and birthing parents experiencing mild to moderate mental illness in the perinatal period. Both organisations were situated within an urban setting; one was based within a ‘mainstream’ Well Child provider, and the second within a Kaupapa Māori health organisation (a Māori health provider that applies Māori values, philosophies and approaches and is Māori-led). Key workers at these organisations shared information about the study with Māori mothers and birthing parents. This information would be shared verbally, and prospective participants were given a written information leaflet about the study, its aims and objectives, who was conducting the study, and contact details. Prospective participants could then contact the lead researcher (CM) directly via phone or email if they were interested in participating. Criteria for participation were intentionally chosen to ensure that the data acquired met research aims (Alordiah & Oji, 2024; Vasileiou et al., 2018). For example, to privilege Māori voices, only Māori parents were approached to participate. Additionally, as the research focus was on experiences of the health service in relation to perinatal mental health, participants needed to have accessed a community perinatal mental health service within the previous 12 months, which is why these two community organisations were chosen as recruitment sites.

Participants

Twenty participants were recruited in total. One participant was excluded as they did not meet the recruitment criteria. Eleven participants were recruited from a Kaupapa Māori health organisation and nine from a more prominent ‘mainstream’ provider. Each participant was interviewed in a space of their choice (their own home or a room provided by one of the organisations or the university). Theoretical sufficiency (Alordiah & Oji, 2024; Fusch & Ness, 2015; LaDonna et al., 2021) was deemed to have been met through a combination of measures. The first involved reviewing the data regularly and evaluating its breadth and depth until theoretical sufficiency was deemed robust enough to meet the study’s aims (LaDonna et al., 2021; Vasileiou et al., 2018). Reaching theoretical sufficiency will vary from study to study (Vasileiou et al., 2018), with no ‘one size fits all’ value and was deemed to have been reached once enough information was acquired to replicate the study and when further coding was no longer elucidating new codes and themes (Fusch & Ness, 2015). For this study, this was achieved after the completion of 19 interviews.

Qualitative Analysis

Once the audio data was transcribed, the interview transcripts were uploaded and analysed with NVIVO software. Prior to commencing any analysis, transcripts were listened to and re-read twice to ensure familiarisation with the data. Prior to commencing analysis, participants were invited to review their transcripts and make amendments or additions. Several cycles of coding were then undertaken. Codes were identified and developed from both deductive coding which utilised a structural framework to order the data, and inductive coding identified in subsequent coding cycles (Saldana, 2021). The initial structural codes were developed from two health and maternity strategic frameworks in Aotearoa, NZ. Those were Te Pae Tata: Interim New Zealand Health Plan 2022 (Te Whatu Ora, 2022b) and Kahu Taurima’s strategic framework for maternity and early years healthcare (Te Whatu Ora, 2022a). These documents were chosen as, at time of analysis, they provided a benchmark for perinatal health best practice in Aotearoa, NZ and were integrated into a framework for the initial structural coding and organising of data. Subsequent coding cycles utilised descriptive coding and pattern coding phases (Saldana, 2021) where the relationships between codes were grouped into categories that explored and critiqued the same phenomenon. Interrelated categories were then clustered to form themes.

The initial analysis was conducted by the lead researcher (CM) and then peer-reviewed by the research team. In-depth discussions were undertaken by the entire team to reach a consensus agreement on the criteria for inclusion within specific codes, categories, and, finally, themes. The Kaupapa Māori research expertise within the supervisory team ensured that participants’ voices were privileged within the analysis and that the principles of Kaupapa Māori methodology were upheld throughout.

Part 3: Kaupapa Māori Methodology as a Facilitator of Culturally Safe Research: A Case Study

The concept of cultural safety emerged from Aotearoa, NZ in the 1990s, where Māori nurses were concerned around the lack of recognition within health systems of the cultural needs of Māori patients (Ramsden, 2002). Decades later, cultural safety remains an important conversation within the field of health as many patients report health professionals providing culturally unsafe care (Graham & Masters-Awatere, 2020; Power Wiradjuri et al., 2022). Cultural safety is equally crucial within health research with Indigenous peoples and supports the researcher to avoid repeating any of the harms previously enacted within research (Ofahengaue Vakalahi & Taiapa, 2013). Cultural safety within qualitative research is essential for ensuring the quality, rigor, and trustworthiness of the research as it ensures researchers do not impose their values, beliefs, and behaviours on the research setting or on research participants. Cultural safety also addresses power imbalances and acknowledges systemic barriers and reduced access to the social determinants of health that contribute to inequities (Brockie et al., 2022; Pelzang & Hutchinson, 2018). For Indigenous populations who have been oppressed and marginalised, cultural safety within research is a fundamental right (Brockie et al., 2022; Wilson & Neville, 2009). Three essential aspects of Kaupapa Māori research methodology have been chosen to illustrate how cultural safety was facilitated within the research process of this project: whakawhanaungatanga (building relationships), whakawhirinaki (building trust), and tikanga (Māori customs and values) (Cram, 2001). These three aspects provided an ethical framework for the research as they were underpinned by the principles outlined within Te Ara Tika (Māori Research Ethics framework) (The Pūtaiora Writing Group, 2010). All three aspects of cultural safety do not occur in isolation but inform each other and occur simultaneously: whakawhanaungatanga and tikanga support whakawhirinaki, the building of trust, while trust strengthens the ongoing relationship, and both the relationship building and tikanga are continuous throughout the research process (see Figure 1).

Figure 1.

Cultural safety in research.

Whakawhanaungatanga | Building Relationships

Whakawhanaungatanga is the process of building meaningful relationships and a fundamental aspect of Māori culture (Stevenson, 2018). Relationships guided this study from the conception of the research aims through to dissemination of the results (Cram, 2001). For example, it was the lead researcher’s (CM) relationships and experiences of working within perinatal mental health settings that led to the initiation of the research project and informed decision making around the development of research questions and aims. Consultation with Māori organisations, communities and families accessing perinatal mental health care ensured that the research aims were informed by their priorities, making the research relevant and meaningful for the participants:

“The question that you asked me before was the most important one because it’s actually the one question that most of the parents I’ve talked to say they’ve never been asked. None of us have ever been asked if we have been provided the care that we actually want and need. So that’s the most important and I think it’s the area that needs the most work (in the system).” (Kāhu*²)

Whakawhanaungatanga and the relationships between the research team and community also facilitated the recruitment process for the project, as the lead researcher was known to the clinicians discussing the research with potential participants. Clinicians were then able to provide assurance that the research process and team were legitimate (Andrighetti et al., 2017). During the qualitative interview phase of the research, utilising the hui process (Lacey et al., 2011; Pitama et al., 2017) ensured that all involved in the interview process understood the roles of researcher and participant and clarified the relationship. The hui process also facilitated the building of relationships and connections between the researcher and participants.

Whakawhanaungatanga involves sharing of self and the building of connections related to whānau, hapū, and iwi links, or whenua (ancestral lands) and involves a certain amount of self-disclosure (Lacey et al., 2011; Pitama et al., 2017). This is a culturally appropriate and safe way for Māori to engage with each other and may differ from Western research engagement methods. For example, one ethical issue often raised within research relates to connections and over-involved relationships between researchers and participants (Allmark et al., 2009). Ethical frameworks provide guidance for researchers, particularly when conducting research with people in vulnerable situations. These ethical concerns arise within Western research paradigms and concerns of professional boundaries (Allmark et al., 2009). However, as outlined earlier in this paper, Western ethical principles have not previously protected Indigenous peoples within research. In contrast, within Indigenous research methodologies, the ability to establish and nurture relationships between individuals and with communities and the ability to strengthen connections are essential research skills, and it is this connectedness and engagement of the researcher that assures their commitment to others (Smith, 2006).

Whakawhirinaki | Building Trust

One of the known challenges identified within perinatal mental health research is the paucity of voices of Indigenous mothers and birthing parents (Meredith et al., 2023). Barriers to recruitment of participants with mental illness include a lack of trust in researchers and feelings of shame and stigma associated with mental illness (Andrighetti et al., 2017). Whilst trust is a known factor for successful recruitment and retention of participants within perinatal mental health research (de Wet et al., 2023), mistrust in research processes is particularly high within Indigenous communities (Brockie et al., 2022). The experience of trauma also impacts on a person’s ability to trust others (Chouliara et al., 2023), and historical and current experiences of trauma are fundamentally linked with the mental health and well-being of Indigenous peoples worldwide (Chamberlain et al., 2019). Consequently, researchers have an ethical responsibility to be trauma-informed within their research practices (Dazzo, 2023). Principles of trauma-informed care have been recommended to be implemented within research and include safety, trustworthiness / transparency, collaboration and reciprocity, empowerment of voices, and cultural, historical, and gender considerations (Camacho et al., 2023). True, culturally safe research practice is inherently trauma-informed as it ensures the recognition of the impact of trauma on individuals, their families, and their community and reduces the risk of re-traumatisation (Tujague & Ryan, 2021). Kaupapa Māori research methodologies are arguably intrinsically trauma-informed as they are grounded in social justice and demand that researchers consider the impacts of colonisation, oppression, and resulting social inequities (Ofahengaue Vakalahi & Taiapa, 2013; Smith, 2002).

Authentic relationship building (through whakawhanaungatanga) was one way trust was built within this research project. Other aspects of the research process that contributed to trust building included upholding tikanga which ensured the enactment of respect, reciprocity, and demonstrating responsibility (Barlo et al., 2021). The principle of respect extended beyond the recruitment, consent and interview processes. For example, being respectful of participants’ knowledge and expertise included ensuring their voices were privileged within the analysis and representing research findings within a strengths-based framework. Reciprocity included ongoing communication between participants and the research team, ensuring publication of research results in open-access journals, and returning to the community to share findings directly. All participants were offered a lay summary of the research findings. The principle of responsibility was woven throughout the research process in the actions of respect and reciprocity described and also through the research team meeting and reviewing the research process regularly to ensure adherence to Kaupapa Māori principles and values.

Previous research has identified factors that motivate women with perinatal mental illness to engage with research. Factors motivating participation included the wish for participants to understand their own experiences, access therapeutic support experienced during the research process, and the opportunity to create a positive experience of a mental illness that has otherwise been challenging and often negative (Andrighetti et al., 2017). Culturally safe research practices can thus provide the opportunity to benefit from participating in research as opposed to experiencing harm from research. Within the trusting relationship created through culturally safe research processes, participants were empowered to share their knowledge and expertise. Having been recruited from providers of perinatal mental health providers, the participants had additional support in place beyond the interview. Combined, these factors created both culturally and emotionally safe conditions for participating in the research, and this was apparent in the length of interviews and time spent with the researcher and the in-depth sharing of their experiences, often including sharing of experiences beyond the research aims and scope:

“Thank you for listening. I was determined to say a lot today. Because I did struggle. And I am very passionate about it, so I left nothing out.” (Manaia*)

Again, the principle of responsibility was crucial, ensuring that participants could safely share without their trust being exploited. This included allowing space for participants to lead the conversation and discuss what they needed to and only utilising data that related to the research questions that participants had consented to. Mitigating and addressing research harm is arguably even more critical in the context of historical and current experiences of trauma and a responsibility that Kaupapa Māori researchers should always uphold. This is in line with Māori epistemology, which is centred on the guardianship of knowledge, ensuring that it is utilised only for the benefit of Māori (Cram, 2006).

Tikanga | Māori Customs and values

Within Kaupapa Māori methodology, it is arguably tikanga that provides the framework of ethical and cultural safety for both researcher and participant (Cram, 2001). Mana Wāhine theory underpinned the study and research processes and created the conditions for enacting tikanga that ultimately facilitated culturally safe research practices. Mana is understood to be the power, dignity, and authority a person has and naturally ensures the sharing of power and control in the research relationship (The Pūtaiora Writing Group, 2010). Within this study, recognising and upholding the mana of the research participants was of utmost importance.

For example, the tikanga outlined within the hui process (Pitama et al., 2007) determined culturally safe engagement, respectful relationships, and established trust between the research team and participants. Tikanga ensured that the social and collective responsibilities of all involved were outlined, with the intention of the research confirmed during the kaupapa stage of the hui process. Upholding mana during the interview process then facilitated ongoing non-linear conversations with active listening and space for reciprocity.

Tikanga also guided the consent process where the mana of participants was acknowledged. For example, during the consent process, it was discussed with participants that the research aimed to utilise their expertise to inform the perinatal health system and improve mental health services within the perinatal period. It was shared with participants that this would be achieved via publishing the study results in open-access journals aimed at disseminating the results of their interviews with those who work in and have an influence on the perinatal mental health system. Participants reciprocated by acknowledging the mana of the research aims, stating they were keen to be involved and to contribute to the research, as they wanted the system to be improved for others:

“I'm super stoked that you’re doing this research. I’m glad I can share my story to actually try and help move (the health system) further and make a difference” (Anahera*)

The tikanga of the poroaki (ending, farewell) part of the hui process provided the opportunity for summarising and reaching a consensus. The poroaki process upheld the mana (dignity) of the participants and continued after the interviews, with the participants checking their transcripts and editing their responses if they wished (Macfarlane, 2013). Another aspect of tikanga was the offering of koha (gift) to the participants in honour of their time and expertise. Koha is a traditional value within te ao Māori (the Māori world), and this may be seen to be at odds with Western research approaches where ethics around honorarium relate to concerns of coercion (de Wet et al., 2023). However, for Māori, the offering of koha is a culturally responsive and appropriate opportunity for researchers to reciprocate the participants’ contributions (Jones et al., 2006).

Discussion

This paper has utilised a case study account to describe the application of Kaupapa Māori research methodology and Mana Wāhine theory and share how these research approaches facilitated culturally safe research practices with Māori mothers and birthing parents. Kaupapa Māori research methodology dictates that research be Māori led and be informed by the priorities of the community being researched and as demonstrated within this case study, is consequently meaningful to research participants. Culturally safe research practices were informed and guided within this study through whakawhanaungatanga (relationship building) and whakawhirinaki (trust building). The trust and relationships developed during the research process continued beyond the interviews, with ongoing conversations during transcript reviewing and the dissemination of research findings. Tikanga (Māori customs and practices) guided the continuity of the relationship, contributed to building trust, and ensured the cultural safety of the research participants and researcher.

Applying Indigenous research principles, incorporating Indigenous knowledges, and integrating community perspectives all have the potential to support the development of effective solutions within the perinatal and mental health system (Haitana et al., 2020; Patterson et al., 2022). Within this study, the foundation of a Kaupapa Māori research paradigm facilitated a collaborative, iterative, and flexible approach to the methods and analysis. The Kaupapa Māori expertise of the supervisory team not only ensured a robust analysis of the data but also guided and supported the lead researcher to be culturally grounded and protect the mana of the Māori participants, honouring their stories and experiences within the data without exploitation or perpetuating harm. This resulted in the data and results being presented in meaningful ways to the participants while still providing salient information to the health system to be used to affect the changes required to address perinatal mental health inequities for Māori.

Acknowledging experiences of oppression is critical when interrogating perinatal health inequities experienced by Indigenous Peoples, and published research infrequently explores the role of colonialism to provide context to these inequities (Patterson et al., 2022). However, this interrogation and acknowledgment requires a sensitive and well-informed approach. Mana Wāhine theory provided a framework for the research team as wāhine Māori to make sense of and interpret the lived realities of Māori participants and to ensure that these realities of wāhine Māori were acknowledged and represented accurately, aligning with the Kaupapa Māori principle of “Getting the story right, telling the story well” (Smith, 2002). Conducting research with mothers and birthing parents places researchers in privileged positions. With this privilege comes responsibility. For Kaupapa Māori researchers, engaging in research with Māori participants, this responsibility and privilege is arguably even more profound and presents the researcher with situations that are sometimes challenging to navigate. The positionality of the team as Māori researchers and the lead researcher (CM) as a Māori midwife meant that the trust and relationships with participants (developed through whakawhanaungatanga) had a depth of understanding and respect that supported safe conversations and elicited a deeper sharing of information. These relationships with participants are situated within a worldview that holds Māori researchers accountable to the participants and wider community beyond the time and context of the research project. The nature of Kaupapa Māori methodology meant that this responsibility was never held by any single member of the research team. The collective approach of an experienced Kaupapa Māori research team ensured not only the cultural safety of the participants but of the lead researcher, too.

Māori and Indigenous parents experiencing perinatal mental illness are in situations of vulnerability, increasing their risk of being exposed to exploitative and harmful research practices. It was, therefore, crucial that the research team safeguarded the participants’ well-being and mana (dignity). Participants of this study were fully engaged in the research process and articulated their enthusiasm and support for the research aims, offering their expertise to inform the study. Kaupapa Māori research methodology and culturally safe research approaches ensured that the solutions offered by participants were outlined in a strengths-based framework to provide a roadmap towards equitable perinatal mental health outcomes. This strengths-based framework aligns with Māori data sovereignty principles which dictate that data collection and interpretation should uphold the dignity of Māori communities and avoid causing any harm through utilising any analysis that stigmatises or blames Māori (Raraunga, 2024). Culturally safe research supports a strengths-based conceptualisation and analysis of research and allows Māori to determine their own needs, solutions, and aspirations for well-being as opposed to having their experiences viewed with a deficit focus (Reweti et al., 2023).

Conclusion

Applying cultural safety to research should begin at the inception of the research idea through to the write up and dissemination of findings (Wilson & Neville, 2009). This paper is not intended to be a checklist of how to conduct research with Māori participants but instead offers insights into why culturally safe research is essential and provides a case study of how Kaupapa Māori methodology can facilitate culturally responsive and safe research practices with Māori mothers and birthing parents. Kaupapa Māori methodologies go beyond checklists as they are grounded in a philosophy of relationship (Haitana et al., 2020) and a mutual recognition of the mana of both researcher and participant (Pihama, 2020). Research ethics with groups experiencing mental illness or distress should be flexible and adopt context-sensitive approaches to mental health research practice and oversight (Lajoie et al., 2020). Engaging in culturally safe and responsive research with Māori supports this flexible approach, can address power imbalances, and ensures that the priorities of the Māori community are centred with the aim to improve the well-being of Māori (Stevenson, 2018).

Footnotes

Acknowledgements

We would like to acknowledge the research participants who offered their expertise and time to this project.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by the Cara Meredith is the recipient of the Health Research Council of New Zealand–Māori Clinical Research Training Fellowship, [grant no: 22/501]

Ethical Statement

ORCID iDs

Cara Meredith

Tracy Haitana

Notes

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