Te hāpai i te mana wāhine, te takahi i te mana wāhine: Māori women’s experiences of empowerment and disempowerment in sexual and reproductive healthcare

Creating comfortable spaces

The spaces we create in healthcare – not just their physical qualities, but more importantly, their warmth, non-judgementalism, and safety – play an important role in the healthcare experiences of wāhine.

Nikita (39) described her experience of arriving at the hospital for a termination:

It was probably the most horrible feeling … talk through a screen, a window that you can’t see anybody, and tell them what you were there for … you could see all these females walking up to that particular room, so you knew exactly what they were there for … you had to tell them what your name was, you had to say this loud, in a big foyer … (Nikita, 39)

Nikita also described a better reception experience from earlier in life, when she went to a student health clinic:

I walked in there, and it was just a room full of people … I didn’t want to say it verbally where everyone could hear me … So she [receptionist] wrote me a note on a little piece of paper and asked, “Do you want a pregnancy test?”, and I was like, “Yes, please”. (Nikita, 39)

While the initial reception area set the tone for the healthcare encounter, the environment and interactions with HCPs were also important for wāhine in facilitating comfort for asking questions and disclosing information.

It’s usually very cold and straight to the point, so it doesn’t leave much room for me to want to ask questions, or feel comfortable talking more about what we’re doing (Maia, 39)

Whina (40) demonstrated how HCPs can increase patient comfort:

Maybe you can just ask “do you have any questions for me, do you want to know anything about me before we start?”. (Whina, 40)

If patients are not voluntarily providing information about their sexual health, or feel uncomfortable asking questions, then it is important that providers consider screening for issues or questions. This does not always happen:

I don’t reckon I’ve been asked about contraception since I had my second child … I don’t think … people ever talked to me about contraception. (Whina, 40)

I just realised then … why hasn’t she talked to me about this before? … she’s been my family doctor for my whole life … whereas all my mates, all their doctors talked to them about it … (Pip, 25)

Ruth (37) suggested that Indigenous women might need prompting to raise SRH issues during consults:

I guess asking more questions when it comes to ethnic women? Because they’re not just gonna say it. (Ruth, 37)

Manaakitanga overcomes barriers to care

Wāhine described wanting staff who were caring, and often preferred female HCPs:

It would have to be a lady doctor. (Aroha, 57)

Wāhine reported that female staff were easier to relate to and provided a relaxing environment:

She [daughter] saw a nurse … she was absolutely lovely and my daughter explained … “I liked her … because she could relate to me … she’s been through the same thing we’re going through.” (Nikita, 39, regarding her teen daughter’s first contraception appointment)

It was all women in there … they just saw me as a woman that needed help … it was very empowering to know that there were other women there to awhi you. (Marama, 50, regarding a termination appointment)

Some of the women preferred staff who were both female and Māori:

Especially a Māori woman … I’m not sure how many Māori women get into it [healthcare] … I find that, even with female doctors, I find that a little bit overwhelming because I don’t see a recognisable female face … If I had a brown woman face with me I think I’d feel a hell of a lot more comfortable because it’s recognisable as someone that’s a safe space for me. (Marama, 50)

I’d be like, “Nah I want a female, and I want a Māori. Or at least a Māori chaperone”. (Nikita, 39)

Two of the wāhine described positive experiences with male general practitioners (GPs) – these cases were associated with long-term continuity of care with their GPs. Anahera’s (35) GP had cared for four generations of her whānau (family), facilitating a doctor–patient relationship that provided a safe space for SRH care:

I had the same doctor for 31 years, which was Dr [name], and he did everything for me … I miss him. (Anahera, 35)

Marama (50) fondly recalled her experience with her long-standing male GP when she presented with an unplanned pregnancy. Their relationship allowed for humour, putting her at ease:

I went to my doctor, who I did feel safe with … he was an older guy, no-nonsense, like “oh well, you’ve done fucked up, you’ve got a belly full of arms and legs now, what are we gonna do?” … I said “I don’t want it”, he goes, “Rightie-o, let’s get you an appointment …”. (Marama, 50)

Some of the wāhine described unpleasant encounters with female staff:

This lady next to me who was supposed to be watching him, and she was just stone cold, she wasn’t comforting or nothing, she was just basically there for him, not for me. (Nikita, 39, describing having a female nurse chaperone for a pelvic exam)

This example, and the examples of positive experiences with male doctors, suggest that the ability of HCPs to provide warm and reassuring care can overcome barriers caused by gender. It is important that wāhine are able to access HCPs who they feel comfortable with. If wāhine experienced more sensitivity when they encounter the healthcare system, they might be more receptive to seeing male staff. Whina states:

I feel like … there needs to be some sensitivity education in medical school, perhaps? (Whina, 40)

Patients are people, not numbers

Participants spoke poorly of experiences that made them feel like they were numbers rather than people. The short duration of GP consults exacerbates this:

They’ve only got fifteen minutes to suss it all out … Are they really getting down to the core of the problem within fifteen minutes? … is it about the money? (Aroha, 57)

Hospital appointments were also experienced to be rushed at times:

Overall … it was good, but it felt like, in and out … like “okay, you’re on your way”. (Joanne, 28, describing hospital care after a miscarriage)

When appointments are too short, patients may not discuss everything they wish to or ask questions, and HCPs lack time for whakawhanaungatanga (building relationship through making connections).

Overly “clinical” care was associated with feeling disconnected from or unseen by HCPs. Marama described her experience of arriving at the hospital in labour as a teenager, having not told anyone that she was pregnant:

They were sort of more like, “she’s got no prenatal history, we don’t know anything about the baby” … they weren’t terribly concerned about anything else, and I was in such a zoned-out, eighteen year-old, “I’m not ready, I’m not ready! I’m pretending it’s not really happening”. (Marama, 50)

Marama also commented that staff simply being “nice” does not quite override the fear associated with termination if care is too clinical:

The doctors were very nice, but they’re very … clinical, which is obviously what they have to be, but it’s very scary. (Marama, 50)

Whina described how SRH requires care with more nuance compared to some other areas of healthcare:

I feel like it’s kind of flippant … I understand that to doctors stuff is just stuff, but in regards to sexual health I think it’s quite a personal thing … I feel like it’s just talked about as if it’s, you know you’ve got a cold or something … (Whina, 40)

Maia (39) told of how, when she miscarried her first pregnancy, she never heard back from her midwife after being referred into hospital:

Throughout that entire time there was just zero contact from the midwife, and we were trying to get a hold of them to help us … ‘cause it was our first time going through it … so that was pretty horrible … we never heard from that midwife again. (Maia, 39)

In contrast, Maia’s second midwife provided a service that was more responsive to her needs:

I reached out to a midwife … had a really good chat with her, told her my feelings about the last midwife I had, and she was really sympathetic, and reassured me that that shouldn’t have happened … she’s been amazing. (Maia, 39)

If wāhine are to trust the system that is responsible for their SRH care, wāhine need to feel that healthcare staff care about wāhine. Whina notes that whakawhanaungatanga can help:

I feel like when someone makes an effort with whanaungatanga, then actually I feel like that, even if it’s just for that fifteen minutes, they’re invested in where I’m at today. (Whina, 40)

The importance of mana-enhancing care

Manaakitanga involves treating others with dignity. The wāhine in this study provided stories of experiencing the opposite of this:

I got the feeling that I may have been a bit of a guinea pig? … ’Cause of who, my race. He didn’t put it out there as that, but I just kind of got a … you know? Sometimes you just feel what you feel (Aroha, 57, regarding experiences of repeated cervical investigations, about which she felt uninformed)

Mere (44) recalled how her GP wanted her to discontinue the contraceptive pill due to her age, but when she asked for information about the Depo Provera injection, the GP would only provide her information about the Jadelle:

He gave me about a fifteen minute lecture on why I shouldn’t still be on the pill … so I talked to him about the Depo, and all the information he printed off for me was regards to the rod … so I left and I was pissed. Because I felt like I wasn’t listened to. (Mere, 44)

At the time of the interview, Mere still did not have any contraception. She also described a dehumanising experience on a delivery ward:

After having [my daughter] within fifteen minutes the nurse came in and said “right get up, get in the shower … you’re being transferred”. And my whole body was just convulsing … I was like, “Oh can’t you just wait?”, and she was like, “No, I want you up now” … she came in fifteen minutes later and said, “Why are you still sitting on the bed, I asked you to have a shower” … she went and got a wheelchair … wheeled me into the shower … it felt like I was a joke. (Mere, 40)

Mere’s experience and that of Marama (described earlier), demonstrate how long the feelings of being undervalued as people in themselves during childbirth can persist, tainting the memories of the births of their children.

Sarah (41) recalled her experience in hospital when she miscarried a pregnancy that she had intended on terminating:

I just think that they … mistreated me a bit unfairly because you knew that you weren’t going to have it … one nurse was quite blunt and said “Well I don’t know why you’re upset, you were going to get rid of it anyway”, but … you’re still sensitive. (Sarah, 41)

Lisa (44) recalled being treated with dignity by the hospital staff during a termination:

They were really good … very supportive, quite lovely. (Lisa, 44)

When wāhine feel disrespected, or don’t have a say in their healthcare, this can damage the relationship they have with HCPs and its therapeutic potential. Mere stated:

We shouldn’t just be pushed to the corner and not allowed to say what we want to say. (Mere, 44)

Strengths and limitations

This is the first study the authors are aware of documenting wāhine Māori experiences of SRH care. As the interviewer (CH) identifies as wāhine Māori, this and whakawhanaungatanga facilitated comfortable dialogue during interviews, resulting in a rich dataset. The age range of the wāhine allowed for the collection of cross-generational data (although older wāhine may have had difficulties recollecting events many years prior). A limitation is that wāhine were not offered the opportunity to read and amend interview transcripts. In addition, only 12 wāhine in one city were interviewed. Further research with more wāhine from different parts of NZ would be valuable, as there is variation in healthcare services across NZ and in the experiences of Māori.

Implications for policy and practice

Clinical services could improve wāhine Māori experiences by ensuring reception areas are welcoming and allow discrete conversation with staff. HCPs need to be aware of their role in helping wāhine to feel comfortable divulging and asking for information – HCPs should use whakawhanaungatanga to build connections with wāhine and build trust. Enhancing the training and recruitment of Māori HCPs within a culturally responsive system, supported by Māori-led services and staff who engage with whānau, can address SRH inequities and expand HCP choice for wāhine Māori. Such HCPs are likely to have a high workload (demand will likely exceed supply), so must be supported by employers to carry this workload and avoid burnout. Finally, HCP training should promote personal reflection and communication skills. Ramsden’s Kawa Whakaruruhau framework⁸ is of vital importance in the training of all HCPs. The Meihana Model³³ is another framework taught to medical students at the Otago University School of Medicine, that guides clinicians in considering how colonisation impacts the health of Māori patients and the importance of facets of Te Ao Māori (the Māori world) to wellbeing. The Model can be used to improve how HCPs provide care for and communicate with Māori, as demonstrated by Al-Busaidi et al.³⁴