New research from the University of Otago, Christchurch, has highlighted gaps in the quality of sexual and reproductive healthcare services delivered to wāhine Māori in Aotearoa New Zealand.
Two papers, both published in the online Journal of Primary Healthcare, report findings from a study which interviewed wāhine Māori about their experiences interacting with the healthcare system for sexual and reproductive health (SRH) issues. They concluded that wāhine Māori often receive insufficient information to allow them to make informed decisions about their healthcare, and that SRH services can leave wāhine feeling dehumanised and disempowered.
Dr Chelsea Harris
Lead author, Dr Chelsea Harris (Ngāi Tahu), a primary care doctor and Teaching Fellow from the Department of Primary Care and Clinical Simulation and PhD Candidate with the Department of Population Health, interviewed twelve Canterbury wāhine Māori, aged between 25-57 years between March and September 2023.
"The wāhine reported that their feeling informed was empowering to them but feeling uninformed resulted in a breakdown of their trust in the healthcare system and an inability to exercise autonomy, or mana motuhake ," Dr Harris says.
"Being uninformed perpetuates health inequities, both indirectly by eroding the trust wāhine have in healthcare services, and directly by limiting the effectiveness of healthcare encounters. Our data showed that wāhine benefit from services and care that make them feel comfortable and respected, but that dehumanising care can impact their future engagement with services."
The papers were the first to report on wāhine Māori experiences of healthcare in relation to a range of SRH topics. The findings were summarised under two key themes, each resulting in a publication.
The first examined the importance of being well-informed in healthcare, with many participants reporting they lacked sufficient information when making decisions about issues such as contraceptive options and diagnostic procedures. They also identified concerns over being kept 'in the loop' when experiencing stressful events such as abnormal cervical smear results, or childbirth not progressing according to plan.
"Many wāhine reported not feeling listened to or being made sufficiently aware of various contraceptive options, with a lack of information resulting in some wāhine discontinuing the contraceptives they'd been prescribed," Dr Harris explains.
Wāhine who described positive experiences during stressful health events felt they knew what was happening throughout the situation, whereas wāhine who reported negative experiences described feeling uncertain, scared and dismissed, which impacted their psychological well-being and trust in the medical system.
"How and when information is provided is so important," Dr Harris says.
"Receiving it immediately before a procedure can be distressing. We know already that women who undergo gynaecological or obstetric procedures without adequate consent are at risk of developing post-traumatic stress disorder or PTSD."
Dr Harris says the paper also highlights that reliable SRH information can be difficult to identify and access. Many wāhine recalled their school sex education was insufficient, with most learning about SRH through personal experience (sometimes with consequences such as unplanned pregnancy), chatting with female family members and peers, or via the internet. While doctors were seen as sources of information, appointments with family doctors were described as being hard to come by, with shyness another barrier.
"Health literacy is often seen as the responsibility of the individual; however previous researchers have argued it's the responsibility of health professionals to support the health literacy of our patient," she says.
"I feel the concept of organisational health literacy is important – the ability of an organisation, including a health service or system, to equitably support health literacy within the population it serves."
The paper says interventions to more widely disseminate reliable SRH information to wāhine Māori could improve outcomes, particularly if Māori-led by design.
The second and follow-up paper focused on the role healthcare professionals and environments play in helping wāhine Māori feel empowered or, conversely, disempowered during SRH.
It found that clinic and hospital environments can be intimidating and counterproductive to maintaining confidentiality.
"The spaces we create in healthcare – not just their physical qualities, but also their warmth, non-judgementalism, and safety – play an important role in setting the tone for healthcare encounters," Dr Harris says.
"This begins in the waiting room. Do patients absolutely need to speak to the receptionist in front of a waiting room full of other people? Are they greeted by a friendly face?"
The paper reported that manaakitanga (kindness and respect) was deemed essential for wāhine to feel safe in clinical settings and to trust their healthcare providers.
"Many women often report a preference for female staff when accessing healthcare for SRH reasons, yet we know that manaakitanga can help wāhine feel more comfortable seeing male healthcare staff for SRH care," Dr Harris says.
"Our mahi reinforced that continuity of care, such as seeing the same healthcare professional over multiple encounters or having the same GP for a prolonged period of time, resulted in doctor-patient relationships which allowed effective and comfortable SRH care to be provided to wāhine by male GPs.
"Also, regardless of gender, the participants reported that a sense of humour was an added bonus!"
The wāhine also noted that short and difficult-to-access appointments were a problem.
"The rushed nature of appointments left some wāhine wondering if it was "all about the money", and one participant expressed concern that fifteen-minute consults could result in misdiagnosis, as she had experienced within her own whānau," Dr Harris explains.
The paper also drew on wāhine experiences of feeling dehumanised during healthcare encounters. The authors concluded that care should support the mana (status or prestige) of the patient.
Dr Harris acknowledges the Meihana Model of clinical assessment (developed by Pitama et al) and the Hui process can be used to accomplish this and to provide culturally safe care for Māori. The Meihana Model is taught to medical students as part of their training at the University of Otago Medical School and as a postgraduate paper accessible to other healthcare professionals.
