Hapū Ora (pregnancy wellness): Māori research responses from conception, through pregnancy and ‘the first 1000 days’ – a call to action for us all

ABSTRACT

Aims

To describe a body of Māori translational research responses that challenge colonialised systems.

Methods

To delineate and link ongoing Kaupapa Māori and Māori-led translational research.

Results

He Tapu Te Whare Tangata explores human papilloma virus (HPV) screening. Te Hā o Whānau presents a culturally responsive framework of maternity care. E Hine describes young Māori mothers’ experiences of Hapū Ora. Severe Acute Maternal Morbidity (SAMM) and SAMM Kids identify opportunities to improve avoidable morbidity. He Tamariki Kokoti Tau – Babies born prematurely, is a qualitative study of Māori experiences of preterm birth. He Tamariki Kokoti Tau – Tackling Preterm, is a quantitative analysis. He Korowai Manaaki is a wraparound maternity pathway. Whānau Manaaki – Methamphetamine aims to reduce the impact of methamphetamine. Calls for action reflect shared desires for system transformation.

Conclusion

We lay the wero (challenge) down to all to transform our current systems. Action is needed!

Abbreviations: HPV: human papilloma virus, SAMM: severe acute maternal morbidity, ICU: intensive care unit, HDU: high dependency unit, RCT: randomised controlled trial, HQSC: Health Quality and Safety Commission.

KEYWORDS:

• Māori
• Kaupapa Māori
• indigenous
• Hapū Ora
• pregnancy
• equity
• perinatal
• infant

Introduction

Preconception, pregnancy and the first 1000 days have been highlighted as a focus for improving wellbeing for whānau (extended family) within Aotearoa New Zealand (New Zealand College of Public Health Medicine 2017). Both good clinical care and wraparound support are crucial for good outcomes for māmā (mothers) and pēpi (infants), leading to timely birth, and lifelong health and wellbeing. Hapū Ora recognises that the health and wellbeing of pregnant māmā ensures the best start to life as the foundation for the first 1000 days (Barnes et al. 2013; Cram 2017). For Māori, who are often failed by the current health system, the best start to life and lifelong health and wellbeing includes the legitimation of Māori ways of being, knowing and doing.

Māori world views recognise that our past is non-linear, we are intertwined – Kia whakatōmuri te haere whakamua (‘I walk backwards into the future with my eyes fixed on my past’) (MacDonald et al. 2013; Rameka 2017). Rameka (2017) writes:

this whakataukī or ‘proverb’ articulates Māori perspectives of time, where the past, the present and the future are viewed as intertwined. From this perspective, the individual carries their past into the future. The strength of carrying one’s past into the future is that ancestors are ever present. The past is central to and shapes both present and future identity. (p. 387)

These perspectives of time are normalised in Kaupapa Māori research – that is, research conducted by, with and for Māori, or, in other words, research with a Māori agenda (Smith 1999; Cram 2017).

Kaupapa Māori research paradigms see being Māori as normal and draw on principles such as Tino rangatiratanga (self-determination), He taonga tuku iho values (cultural aspirations), Ako (culturally preferred pedagogy), Kia piki ake i ngā raruraru o te kainga (socioeconomic mediation), whānau, and Kaupapa (collective philosophy) (Cram 2017). Tino rangatiratanga ensures that Kaupapa Māori research is by, with and for Māori. He taonga tuku iho are gifts that have been handed down such as Māori tikanga (customs), te reo (Māori language) and Mātauranga Māori (knowledge). This then encompasses te reo me ōna tikanga (Māori language and customs).

Oriori (lullabies/chants) are an example of he taonga tuku iho encompassing Mātauranga Māori and Pūrākau (Māori cosmogeny) as a means of passing on knowledge through te reo me ōna tikanga, with particular relevance to Hapū Ora. Whānau compose and recite oriori as a sacred ritual, both to the unborn child and the pēpi. This welcomes them into the world as a mark of respect for the new life and in recognition of the capacity of the very young to learn (Rameka 2017). Oriori are a way of reminding a pēpi of their place in the world, of the journey that lies ahead. They reinforce the connections that bind people to one another, reminding us of our roles and responsibilities (Penehira and Doherty 2013).

The oriori ‘Pinepine te Kura’ (‘Little Tiny Treasure’) (Te Ao Hou 1964) is significant to our Kaumātua (knowledge holders) and relates to the research work we are undertaking or have undertaken to date. ‘Pinepine te Kura’ was composed for a young or unborn pēpi from Ngāti Kahungunu. This oriori was used to transmit wisdom and the knowledge necessary for the upbringing of the pēpi, and to voice the dreams and aspirations of the whānau for their precious ‘kura’ (treasure). The research team are mindful of the intellectual property held in waiata and that oriori is essential (Ka’ai-Mahuta 2010). ‘Pinepine te Kura’ has informed a ‘blueprint’– the envisioning of an optimal pathway for pēpi and whānau – which is Kaupapa Māori, i.e. by Māori, for Māori. Other examples of he taonga tuku iho include Pūrākau such as that of Hine-te-iwaiwa (goddess of childbirth and weaving) who protects hapū māmā. When looking to the past through he taonga tuku iho, a pathway to the future is envisioned where pēpi and whānau are precious and their strength and potential, as Māori, are celebrated, from which we learn that Hine-te-iwaiwa protects hapū māmā. Research to support Hapū Ora recognises this, and the right for Māori to flourish as Māori (Durie 2003).

This paper aims to describe a body of Kaupapa Māori and Māori-led research focusing on approaches to preconception, Hapū Ora and the first 1000 days. This research, along with international collaborations and calls for action, challenges colonialised systems to achieve tino rangatiratanga and equity for indigenous peoples and their pēpi as a fundamental right.

Methods

Aim

To describe and provide a commentary on a significant body of published and ongoing Kaupapa Māori and Māori-led indigenous research, focusing on preconception, Hapū Ora and the first 1000 days and beyond.

Methodology(/ies)

Kaupapa Māori research is research that is by, with and for Māori. It sees being Māori as normal. Concepts such as he taonga tuku iho position wāhine Māori, pēpi and whānau at the centre of research – as experts, upholding community aspirations, development, and sovereignty (Cram 2017). In valuing and privileging Māori experiences, Kaupapa Māori research challenges current inequitable systems to transform to ensure the best health outcomes and wellness for Māori as Māori (Cram 2017). System transformation towards tino rangatiratanga is a pathway towards equity (Smith 1999; Cram 2017). Similarly to Kaupapa Māori research, Māori-led research is led by a Māori principal investigator and includes non- Māori colleagues/allies working collaboratively together in a strengths-based approach. Māori-led research involves Kaupapa Māori concepts and may also draw on other methodologies and include non-Māori participants. Projects led by Māori scholars can involve a conscious and careful working relationship with non-indigenous (Hoskins and Jones 2017), and non-indigenous researchers, with a genuine desire to support the cause of Māori, can be included as colleagues and ‘useful allies’ (Bishop 1994). Indigenous, as defined by the United Nations (United Nations 2007), led research is research that is determined by indigenous peoples. The body of work described in this paper emphasises the significance of Kaupapa Māori, Māori-led and indigenous-led research.

Research partnerships

This work has been produced and developed by a collective of Kaumātua, whānau advisors, Māori and non-Māori scholars, and international collaborators (both indigenous and non-indigenous). Kāhui Māmā (collectives of mothers with lived experience) provided guidance in the development of the research mahi (work) for E Hine and He Tamariki Kokoti Tau – Babies born prematurely. A Kāhui Kaumātua (collective of knowledge holders) (Matthew Bennett, Charlie Lambert, Dame Areta Koopu, Wendy Dallas-Katoa, Warihi Campbell), plays a pivotal role in our research. The Kāhui Kaumātua provides guidance on tikanga that supports the project teams to navigate and operate within Māori contexts. The Kāhui Kaumātua have been involved in all aspects of the research described, from conception of ideas through to interpretation of results, and continue to guide the overall kaupapa.

As part of these ongoing relationships, input and support from within communities and iwi have been an integral in this process. The members of the research team have varied depending on mahi at the time. Originally based within the University of Otago and now within Te Herenga Waka Victoria University of Wellington as Te Tātai Hauora o Hine, this large collective work fundamentally approaches research from a strengths-based approach to affect policy. The vision is to reduce preventable harm and death for wāhine, pēpi and whānau, improve health outcomes over time, affect policy and have impact for lifelong health and wellbeing for whānau.

The Kaupapa Māori research principles described, such as tino rangatiratanga and he taonga tuku iho, are integral to the research presented (Cram 2017). The principal Ako acknowledges that we are all on a learning journey together as part of the research process. This is reflected in the work with Kaumātua and researchers on a learning journey together. Kia piki ake i ngā raruraru o te kainga recognises the impact of influences such as the social determinants of health and the impact on health outcomes and wellbeing. Kaupapa Māori research acknowledges these challenges and allows for interventions that mitigate some of these pressures on health and wellbeing. Whānau and kaupapa are an integral part of the preconception, Hapū Ora and first 1000 days and Kaupapa Māori research involves whānau, hapū (kinship groups) and iwi (tribal groups) in partnership.

Ethical approvals

All studies included within this article have received ethical approval by the Health and Disability Ethics Committee (HDEC), New Zealand or university-based institutional ethics committees, and, where relevant, locality approval by the local District Health Board.

Results

The results in this section are presented sequentially from preconception through to the postnatal period. He Tapu Te Whare Tangata – The sacred house of humanity, explores HPV screening to prevent cervical cancer (Adcock et al. 2019a, 2021a; MacDonald et al. 2021). These studies included a cluster randomised control trial (RCT) alongside qualitative studies exploring HPV self-testing. The continuation of whakapapa (genealogy) is crucial for the survival and flourishing of whānau, hapū, and iwi. The adage He Tapu Te Whare Tangata indicates the reverence of Māori women and people with cervices as ‘whare tangata’ (houses of humanity) and the sacredness of the womb, also known as ‘whare tangata’ (the house in which all human life grows), for their vital role in this continuation (Adcock et al. 2021a). Persistent inequities in reproductive, maternal and pēpi health outcomes compromise the ability of Māori whānau, hapū, and iwi to flourish as Māori (Cram 2017). Hapū Ora starts before conception. As the neck of the womb, the health of the cervix impacts the ability of the womb to fulfil its role as the whare tangata, and the ability of women and people with cervices as whare tangata to lead long and healthy lives. Cervical screening and early treatment for cervical pre-cancerous changes are important for a healthy cervix, free of cervical cancer. Looking for HPV is more effective than cytology as primary cervical screening to prevent cervical cancer, and it can be done by a self-test using a vaginal swab. Significantly, being able to self-test for HPV reduces barriers to screening (Adcock et al. 2019a, 2021a; MacDonald et al. 2021), and, therefore, has the potential to support He Tapu Te Whare Tangata, by addressing inequities in access to cervical screening and follow-up for Māori. Ongoing HPV research, in partnership with iwi in rural areas of Aotearoa, is exploring whether innovative rapid point-of-care technology, combined with HPV self-testing and appropriate follow-up support, improves access to colposcopy (examination of the cervix). Findings from these studies will have significant implications for the broader delivery of rural health services and indigenous health (Lawton et al. 2020a).

Moving from preconception and cervical health to Hapū Ora, Te Hā o Whānau presents a culturally responsive framework of maternity care (Stevenson et al. 2020a, 2020b). Following a qualitative kōrero (discussions and interviews) with whānau who had experienced maternal-infant intensive care spaces (e.g. neonatal intensive care units and/or special care baby units), a framework was developed to help these spaces be culturally responsive for whānau following the harm and/or loss of their pēpi. This framework seeks to align tikanga Māori, such as manaakitanga (respect, kindness, support), whanaungatanga (relationship), and rangatiratanga, with clinical care so that whānau can receive best evidence based high quality culturally responsive care. This framework is currently being tested at Starship Hospital in a feasibility study. If deemed feasible, a larger study will see the implementation of the framework across maternal-infant health care systems in Aotearoa New Zealand.

E Hine was a Kaupapa Māori qualitative longitudinal study exploring the experiences of young Māori mothers in pregnancy and early childhood years (Lawton et al. 2013, 2016; Adcock et al. 2016, 2019b, 2021b; Stevenson et al. 2016; Cram et al. 2021a; Dhunna et al. 2021). This project uncovered a vast range of issues from the depth of experiences of these māmā. We learnt that the birthing experiences of these young māmā often included racism, stigma, mental health stresses, poorer access to Lead Maternity Carers (even though they were actively seeking maternity care), and housing stresses. Health and wellbeing needs must be addressed for these young māmā. Key to this has been changing the narrative of young motherhood from a stigmatised event to an event deserving of support and celebration, as young women and their partners become new parents. Findings have informed advocacy to improve connection to midwifery care during pregnancy, contraception provision following birth, welfare support for young whānau, and the provision of quality, affordable housing close to whānau supports for those wanting to live independently.

Severe Acute Maternal Morbidity (SAMM) is a Māori-led project that identified opportunities to improve maternal health outcomes and avoidable morbidity (Lawton et al. 2010, 2014, 2018; MacDonald et al. 2015, 2016, 2019; Cram et al. 2018; Geller et al. 2018; Furniss et al. 2018; Lepine et al. 2019). These studies used an internationally validated preventability tool and multidisciplinary panels of experts to audit real cases of severe maternal morbidity, involving audit and retrospective chart reviews with Kaumātua guidance. They highlighted that two-thirds of the cases analysed were preventable or needed improvement in care and most of the preventability was due to clinician factors such as delay in diagnosis and delay or inappropriate treatment. All cases were de-identified for ethnicity to minimise racism in the case reviews – the first national study on SAMM to address racism through this process. Results were reported with an indigenous non-deficit focus looking for system improvement opportunities, and have been presented nationally and internationally. Following this study, the New Zealand Ministry of Health funded the translation of the SAMM process to the Health Quality and Safety Commission (HQSC) to establish SAMM reviews (MacDonald et al. 2019).

The SAMM Kids study examined the outcomes of pēpi whose mothers had a SAMM (Lawton et al. 2020a) and the potential preventability of associated adverse fetal/neonatal outcomes (Lawton et al. 2021a). SAMM events were associated with high rates of adverse fetal/neonatal outcomes, with a higher burden of adverse events for pēpi of Māori wāhine. As in keeping with SAMM, to minimise potential racism, the ethnicity of pēpi was not identified and results were reported with an indigenous lens and a strengths-based approach. The postnatal experience is a component of Hapū Ora and the first 1000 days, factors that impacted on māmā and pēpi post-delivery related to common and potentially preventable neonatal conditions – neonatal hypothermia and neonatal hypoglycaemia. Provider factors (errors) were the major contributor in these potentially avoidable conditions. SAMM and SAMM Kids were Māori-led studies supporting equity and the kaupapa of reducing Māori māmā and pēpi mortality and morbidity (Lawton et al. 2010, 2014, 2018, 2021a; MacDonald et al. 2015, 2016, 2019; Cram et al. 2018; Geller et al. 2018; Furniss et al. 2018; Lepine et al. 2019). These studies are considered part of Hapū Ora as they contribute to our understanding of perinatal outcomes.

He Tamariki Kokoti Tau – Babies born prematurely, is a Kaupapa Māori qualitative longitudinal study of whānau experiences of preterm birth (Adcock et al. 2021c). This research followed Māori whānau who had a preterm pēpi until their first birthday. The goal is to ensure health services are responsive to the needs and aspirations of Māori. This study found that preterm birth can be an emotional roller coaster for whānau. Being familiar with hospital routines, staff, peers, pēpi care, and being wrapped in wider whānau support were key for whānau coping. This emphasises the importance of whakawhanaungatanga (processes of establishing relationships) to create safe spaces for whānau to be themselves. This research has been presented nationally to neonatal intensive care units involved as part of a knowledge transfer process.

He Tamariki Kokoti Tau – Tackling Preterm, is a quantitative analysis of retrospective preterm data (Filoche et al. 2018; Edmonds et al. 2021) focusing on outcomes for Māori. The premature birth of pēpi affects many whānau, with systemic privilege and advantage occurring. European women have lower rates of premature birth and improved survival. This suggests that the current maternity system privileges whiteness. Improving rates of term birth for whānau have the potential to improve lifelong health and wellbeing, including in the first 1000 days. The learnings from this research will be presented nationally and internationally and demonstrate current outcomes in order to hold the current system to account and issue a wero for system transformation in the future (Hickey et al. 2021).

He Korowai Manaaki is a Kaupapa Māori maternity care pathway with wraparound support including transport, oral health care, and enhanced navigation of hapū māmā to health care providers (Adcock et al. 2019c; Lawton et al. 2021b). This study builds on the learnings from the E Hine study. Kaumātua Matthew Bennett gifted the name of this study, with the different services and augmented support offered represented as threads of the korowai (cloak), wrapped around the hapū māmā. This pathway is evidence of culturally responsive research where collaboration with iwi promotes a strength-based approach to improve outcomes. The pathway involved a process from asset mapping (Adcock et al. 2019c), through to a cluster RCT of a clinical care pathway (Lawton et al. 2021b). He Korowai Manaaki informed an urgent response to the COVID-19 pandemic. Researchers, clinicians, and iwi developed the Hapū Māmā Connecting toolkit which was made available through Te Rōpū Whakakaupapa Urutā (Māori Pandemic Committee) and the Royal New Zealand College of General Practice to assist hapū māmā being connected to time-sensitive care. The toolkit was also shared through international networks to urgently address equity issues worsened by COVID-19 (Lawton et al. 2020b).

Whānau Manaaki – Methamphetamine (a strength-based community approach for hapū māmā) is currently being undertaken (Lawton et al. 2019). Whakapounamu Mana Wāhine – Wāhine Māori are the bearers of our whakapapa. The whakapapa and the impact of methamphetamine on Hapū Ora is important to whānau, hapū and iwi. Ngāti Pāhauwera has responded by taking up the wero in this iwi-led Kaupapa Māori partnership with Te Tātai Hauora o Hine to achieve the best health outcomes possible for Māori wāhine, pēpi and their whānau. This research aims to contribute to and explore the impact of methamphetamine on the health and wellbeing of Māori pregnant women, their pēpi and whānau, map existing services and co-design interventions to reduce harm. To date this research has enabled local community researchers and networks to work alongside whānau and listen to their kōrero.

The publication ‘A call for action that cannot go to voicemail’ is an example of research activism to urgently improve indigenous perinatal health and wellbeing, and is an international collaboration of indigenous and non-indigenous researchers (Hickey et al. 2021). This paper arose from a shared international recognition of indigenous health needs around preconception, Hapū Ora and the first 1000 days. All too often, calls to action are made with no systemic or persistent change. Kaupapa Māori research principles provide opportunities for systemic change in health outcomes. Other calls to action for indigenous and First Nations women’s health and wellbeing included a special issue of the International Journal of Gynecology and Obstetrics, ‘A Call for Action in Indigenous and First Nations Women’s Health and Wellbeing’ (Lawton et al. 2021c). Te Tātai Hauora o Hine researchers were part of the multidisciplinary guest editor team of indigenous and non-indigenous women’s health experts in Aotearoa New Zealand and Australia for the special issue, which included 16 papers by indigenous researchers and the call for urgent transformation of systems. HPV screening to prevent cervical cancer has also been highlighted, with a published policy statement to address the burden of HPV disease for indigenous peoples, providing momentum for change, reflecting a shared desire internationally for change (Lawton et al. 2020a).

Table 1 provides more detail of some of the studies described above.

Table 1. Research summaries.

Kaupapa (study/work)	Description	Learnings
He Tapu Te Whare Tangata: The sacred house of humanity (Adcock et al. 2019, 2021; MacDonald et al. 2021).	Cluster RCT (MacDonald 2021) Māori-led research. Aim to increase cervical screening for under/never-screened Māori women. Intervention arm an HPV self-test and the control arm standard care (a cervical smear).	Māori women in the intervention arm were 2.8 times more likely to be screened than women in the control arm. HPV self-testing, potentially halving the number of under/never-screened Māori women and decreasing cervical morbidity and mortality. Findings are potentially generalisable to other under/never-screened indigenous populations. This study informed the change to the National Cervical Screening Programme anticipated July 2023*.
	Kaupapa Māori qualitative studies exploring the potential acceptability of HPV self-testing for never/under-screened Māori women by Kaupapa Māori mixed methods, involving hui (focus groups/interviews) and survey (Adcock 2019, 2021).	HPV self-testing is acceptable for never/under-screened Māori women. Three in four survey participants signalled that they would accept the self-test if offered it. Self-collected HPV tests remove barriers of whakamā (embarrassment/shyness), bodily autonomy (privacy, control over one’s body) and tapu (sacred/taboo) that Māori women report to experience with standard care. Recommendations made for a culturally competent HPV self-testing cervical cancer prevention programme.
Te Hā o Whānau – a culturally responsive framework of maternity care (Stevenson et al. 2020a, 2020b).	Kaupapa Māori qualitative study in which Māori women and their whānau told their stories following the loss of, or harm to their pēpi to investigate the impact of being transferred to either secondary or tertiary hospitals for care during and/or following birth (Stevenson 2020a).	Māori whanau experienced a lack of Tikanga manaakitanga, Tikanga rangatiratanga and Tikanga whakawhanaunga in maternal-pēpi health care. The absence of Tikanga Māori reflected on Māori feeling powerless compared to health practitioners, unconnected to the place and people, and absence of respect for cultural practices. The study informed the development of Te Hā o Whānau.
	Kaupapa Māori Te Hā o Whānau is a health care framework, developed to aid the maternal-infant health care system becoming a culturally responsive and accessible system to Māori and achieve better health outcomes for all (Stevenson 2020b).	The provision of Te Hā o Whānau will guide the delivery of culturally responsive care for whānau to achieve better maternal-infant health outcomes. Building new pathways inclusive to mātauranga Māori engenders the opportunity to create new, appropriate knowledge and practices to align Māori and Pākehā world views for best outcomes. Pilot currently occurring at Starship Hospital.
E Hine: Reducing Barriers to Care for Pregnant Māori Women under 20 Years and Their Infants (Lawton et al. 2013, 2016; Adcock et al. 2016, 2019b, 2021b; Cram et al. 2021; Dhunna et al. 2021; Stevenson et al. 2016).	E Hine: access to contraception for indigenous Māori teenage mothers focused on contraception access pre- and post-pregnancy Māori-led research. This analysis aimed to identify barriers and facilitators to accessing contraception (Lawton 2016).	There was a marked lack of seamless integrated contraceptive care and provisions for these women both pre-conception and post-partum. Barriers to appropriate contraception occur at systemic and clinical levels. Recommendations following this study included improved service models including immediate post-partum IUCD or implant insertion, and extension of midwifery competencies to include insertion of IUCDs and implants.
	Kaupapa Māori research E Hine: Young Māori women’s journeys through pregnancy, birth, and motherhood explored the longitudinal journeys of 15 of the young women, looking specifically at the transitions that occurred through their journeys during pregnancy, birthing and early motherhood drawing on a Foucauldian theoretical approach (Adcock 2019b).	Young Māori pregnant women and mothers are subject to Eurocentric medical, disciplinary, and colonial gazes –through exclusionary health, education, and social services, and public prejudices – that see them as abnormal and in need of regulation. Often with the support of their whānau, the participants challenged assumptions about teen mothers. They strove to be the best parents that they could be, often re-engaging with education and working hard to provide a positive future for themselves and their children. This study provides an opportunity to improve care for young mothers.
	Kaupapa Māori research E Hine: Young Māori mothers talk about welfare benefits examined the young women’s experiences of accessing welfare benefits through Work and Income when their infants were around two years old (Cram 2021).	Accessing welfare benefits was fraught for these women, with problems ranging from stigma and discrimination to a lack of consistency. The key findings of this study present an opportunity to make changes to Work and Income’s systems to ensure support is provided in a way that is culturally appropriate, easy to navigate, and equitable.
	Kaupapa Māori research E Hine: Talking about Māori teen pregnancy with government groups is a qualitative study that interviewed individuals from across six government agencies (Adcock 2016). It aimed to understand not only what support was available for young Māori mothers, but the attitudes of workers in these agencies, and the structural barriers and facilitators to equitable health care.	Interviews covered both individuals’ views on what their agency did to help young Māori mothers and structural issues. The research found an absence of resources, organization, and mention of Māori in both talk and policy. Recommendations were made to address the barriers in order to successfully deliver policies and initiatives that meet the needs of young Māori mothers and their infants.
	Kaupapa Māori research Lived Realities: Birthing experiences of Māori women under 20 years of age explored the birthing experiences of 16 Māori women (Stevenson 2016).	Four key themes emerged: some tikanga Māori are still practised; whānau support is crucial; system issues impact negatively on birth experiences; and adaptation to motherhood varies. Recommendations made included promoting positive communications between patient and providers, facilitating supportive whānau environments, and enhancing support services accessibility.
	Kaupapa Māori research: Developing a Kaupapa Māori Research project to understand health disparities experienced by young Māori women and their babies and describes consultation to seek agreement for research with young Māori mothers in two regions (Lawton 2013).	Endorsement was gained for strength-based research with young pregnant Māori women and their babies. The engagement processes, consultation and relationship building that were part of the community-led research practices in this study are described and offer information essential for the design of a protocol for an intervention based on whānau ora and can inform policy.
	Kaupapa Māori research ‘It feels real good having my own space’ – Young Māori Mother in the E Hine Study Talk About Housing explored the housing journeys of the 37 young women who remained in the study when their infants were 2–3 years old, using reflexive thematic analysis (Adcock 2021).	Three themes were developed. First, ‘Seeking spatial autonomy: The importance of finding one’s own space to parent’ relates to the importance placed, by the young women, on having their own space. Second, ‘Relational beings: The tensions of relational autonomy for young parents’ attends to the desire of the young women for spatial autonomy while still being embedded within support networks. Finally, ‘Material dilemmas: Aspiring to make a “home” during a housing crisis’ explores the material challenges faced by the young women. The paper calls for urgent action to implement Te Tiriti o Waitangi-compliant housing policy for young whānau – policy that respects their need for autonomy, protects their sense of agency, and allows them to raise their children in a place they can call home.
	Kaupapa Māori research An affront to her Mana: Young Māori mothers’ experiences of intimate partner violence (Dhunna 2021).	This study analysed six narrative interviews from E Hine. Their stories showed the various ways in which young Māori women resist violence, reclaim their Māori identities, and experience personal transformation during their motherhood journeys despite abuse. We find that whānau (extended family) is both a violence-perpetuating and immensely protective factor. Moreover, there are structural and institutional barriers to culturally safe service responsiveness for young Māori women. These come in the form of racism at the frontlines of government agencies, pervasive victim-blaming, and a lack of earnest decolonial structural change at the institutional level.
Severe Acute Maternal Morbidity (SAMM) (Lawton et al. 2010, 2014, 2018; Cram et al. 2018; Lepine et al. 2019; MacDonald et al. 2015, 2016, 2019; Furniss et al. 2018; Geller et al. 2018)	A retrospective audit of 29 cases (pregnant women admitted to a NZ Intensive Care Unit) to describe clinical, socio-demographic characteristics, pregnancy outcomes and preventability Māori-led research (Lawton 2010).	Of the cases 35% were deemed preventable. A recommendation was made for a prospective national severe acute maternal morbidity (SAMM) audit process to be introduced in Aotearoa as a quality of care measure.
	Retrospective audit of 98 SAMM cases in four DHBs during a 17-month period. Cases were reviewed by external multi-disciplinary panels using a validated model for assessing preventability Māori-led research (Lawton 2014)	Of the cases 38.8% were deemed potentially preventable and in a further 36.7% improvement in care was needed. Themes around substandard care related to delay in diagnosis and treatment for postpartum haemorrhage and septicaemia were identified. This study was subsequently expanded to a national New Zealand audit of all SAMM cases admitted to an Intensive Care Unit (ICU)/High Dependency Unit (HDU).
	National retrospective review of pregnant or postpartum women admitted to an ICU/HDU during pregnancy or recent postpartum. Outcomes were rates of SAMM and assessment of potential preventability Māori-led research (Lawton 2018; Lepine 2019; MacDonald 2020)	Multidisciplinary external anonymised review of SAMM (339 cases) showed that over a third of cases were potentially preventable, being due to substandard provider care with increased preventability rates for racial/ethnic minority women.
	Kaupapa Māori research involving nine women who had experienced a SAMM resulting in admission to ICU/HDU (Cram 2018). These unique experiences were captured and gave insight into the lived experiences of the women from their pregnancy to the hospital setting and adjustment to their normal lives again.	The study highlighted the struggles these women had to unexpectedly endure. It highlighted the importance of having whānau and partner support and the adaptations they make to accommodate for the pēpi and the mother. It showcased the discrepancies in information which is shared as most of the mothers heard about their experiences secondhand from their whānau members. These interviews indicate the importance of change at a system level which would include hospital protocols which allow partners to be accommodated on site to care for the baby while the mother is being cared for. The findings are also suggestive of the importance of an understandable explanation by the medical team of their SAMM event.
SAMM Kids (Lawton et al. 2020, 2021).	National retrospective cohort study examining cases of SAMM with an adverse fetal/neonatal outcome Māori-led research (Lawton 2020, 2021). Adverse fetal/neonatal outcomes of mothers who had a SAMM event.	Adverse fetal/neonatal outcome was potentially preventable in 55.3% of cases. Study identified opportunities to improve fetal/neonatal outcomes associated with SAMM.
He Tamariki Kokoti Tau: Families of Indigenous Infants Talk about Their Experiences of Preterm Birth and Neonatal Intensive Care (Adcock et al. 2021)	A cross-sectional interpretative phenomenological analysis of first interviews with 19 whānau participating in a Kaupapa Māori (by, with, for Māori) qualitative longitudinal study of preterm birth (Adcock 2021).	Four superordinate themes were identified. Preterm birth was an emotional roller coaster for whānau, with the birth imaginary and anticipated roles disrupted. Being close to their infants was a key priority for whānau. When health practitioners or hospital policies inhibited this, whānau were frustrated. Being familiar with the hospital environment, infant care, and being wrapped in wider whānau support were key for whānau coping.
He Tamariki Kokoti Tau – Tackling Preterm (Filoche et al. 2018; Edmonds et al. 2021).	A Māori-led research retrospective cohort study of preterm deliveries from 2010 to 2014 exploring neonatal outcomes and infant mortality in relation to the antenatal care pathway and risk factors for preterm delivery.	European women had significantly less risk of having an extremely preterm or very preterm pēpi. European women had a significantly lower rate of neonatal death or postnatal death. These results highlight to us that in the Aotearoa New Zealand maternity system there is a whiteness privilege.
He Korowai Manaaki (Adcock et al. 2019; Lawton et al. 2021).	A prospective study in Te Wairoa of an indigenous-led wraparound maternity care pathway. Informed by Kaupapa Māori research Aka Mātua (a strengths-based asset mapping approach) (Adcock 2019). The aim of this wraparound maternity care pathway is to improve maternal and child health outcomes and improve access to services.	Recruitment commenced in February 2018 and was completed in September 2019. Publication of results is anticipated early 2023.
	A Kuapapa Māori research cluster RCT involving eight primary care practices (Lawton 2021).	The intervention arm is an augmented maternity care pathway (He Korowai Manaaki) offering clinical care through additional paid health care appointments and improved access to social support (e.g. housing, transport). The control arm is usual care. Recruitment commenced in November 2018 and was completed in June 2020. Publication of results is anticipated in late 2023.
Whānau Manaaki: Methamphetamine – a strength-based community approach (Lawton et al. 2019)	Kuapapa Māori research qualitative study brings together experiences of wāhine and whānau along with that of key informants and stakeholders to fill in the knowledge gaps and map existing services and successful interventions.	Underway 2020–22, this study seeks to inform the co-design of intervention and policies to combat methamphetamine harm experienced by women and infants. Publication of results is anticipated late 2022.
A call for action that cannot go to voicemail: research activism to urgently improve indigenous perinatal health and wellbeing (Hickey et al. 2021).	Research activism to urgently improve indigenous perinatal health and wellbeing – an internal collaboration of indigenous researchers. This call-to-action article is designed as a statement to initiate action to support and resource indigenous-led perinatal health services.	This described action research leading change for indigenous perinatal outcomes, embedding indigenous governance, increasing indigenous in the workforce, and improving cultural capabilities which will require resourcing. Support from service providers, policymakers, health service funders, government, and the public to action indigenous-led health services and improve indigenous perinatal health and wellbeing is required.
The lives of women and babies matter: A call for action in Indigenous and First Nations women’s health and wellbeing (Lawton et al. 2021).	Special Issue of the International Journal of Gynecology and Obstetrics. Te Tātai Hauora o Hine researchers were part of the multidisciplinary guest editor team. The special issue included sixteen articles about strengths-based women’s health research, led and conducted by indigenous researchers	The issue highlights the voices of those usually not heard in research, in clinical care, and in health service design, to challenge the norms of women's health care provision and reject the silence and acceptance around indigenous disparities in death and morbidity. The issue called for the urgent transformation of systems and individual behaviours to achieve equitable outcomes for indigenous peoples.
IPVS Policy Statement addressing the burden of HPV disease for indigenous peoples (Lawton et al. 2020a).	International Papilloma Society (IPVS) Policy Statement addressing the burden of HPV disease for indigenous peoples. A call for action. This call for action was developed by the International Indigenous HPV Alliance (IIHpvA) co-chaired by B Lawton.	It states that ‘it is paramount that the HPV research and practice community supports culturally appropriate best practices in research and policy to reduce this burden of disease. This statement outlines the origins of this burden, the fundamental requirement to work with Indigenous peoples to reduce this burden, and makes recommendations for actions.’

*New Zealand Parliament. Health (National Cervical Screening Programme) Amendment Bill – Third Reading 2021. Available from: https://www.parliament.nz/en/pb/hansarddebates/rhr/combined/HansDeb_20210623_20210623_40.

Discussion

Kaupapa Māori and Māori-led translational research studies provide evidence to inform and lead to transformational change to ensure health equity. The body of work described here responds to the wero of tino rangatiratanga through collaborative work informing indigenous health solutions and meeting local and global calls for action. These studies provide models of research led and undertaken by Māori, for Māori. They provide solutions to improve health and wellbeing from preconception, Hapū Ora and the first 1000 days and beyond, and to transform health care from current systems that privilege whiteness. All too often Māori whānau have shouldered the burden of poor health outcomes as a direct result of colonisation and racism within a system that does not meet their health needs, and which continues in our contemporary experience. The research reflects the commitment to follow up questions raised by the community, Kaumātua and previous research to build upon the strengths and findings for whānau in Aotearoa. Leading from this is the potential to support indigenous whānau worldwide with collaboration between indigenous researchers. The use of Kaupapa Māori methodology and Māori-led translational and transformational research is an academic approach that brings a depth to our research that is, in the words of our Kaumātua, more vibrant and more living than a static intellectual or fact-finding exercise. From the commencement of these research relationships the teams have embraced influencing policies and health system transformation.

System transformation is embedded within all aspects of the mahi described here. Kaupapa Māori principles, such as taonga tuku iho, allow the research team to uphold Māori concepts including space and time (Durie 2017). From a research perspective there is often an elongated time period before research is translated into practice. In contrast, the research described here has had an impact and reduced the dimensions of time and space. This then has led to a more rapid effect on policies and subsequent actions. An example of this is demonstrated in He Korowai Manaaki, from community asset mapping involving whānau through to intervention and Kia piki ake i ngā raruraru o te kainga (socioeconomic mediation). For example, identifying what is currently available within the community and what is less accessible (such as oral health). The whakatauki, Kia whakatōmuri te haere whakamua frames the research mahi. The time invested allows for the development of meaningful relationships with communities and iwi, and using a Māori world view enables system transformation to be realised.

Other temporal concepts are seen in the research described. For example, the oriori ‘Pinepine to kura’ (‘Little Tiny Treasure’) could be described as a pathway, a journey to take up the prospect of leadership, and to realise their untapped potential within the womb. Our past reflects the coming of generations, of whakapapa, creating the space for growth, for transformation, allowing the time to rebuild, revitalise and rebirth. It is in that space of future generations. Our space is Te Ao Hurihuri (ever-changing world) and we have inherited these gifts to continue to flourish. This is an indigenous model around which health views, experiences and our research are anchored. A Kaupapa Māori approach to the research has significant impact. It allows the reduction of time and space between cause, effect and implementation. This is the wero laid down to Te Tātai Hauora o Hine and they have responded though the research described.

Limitations

There is additional Kaupapa Māori research which is not described in this paper. Other linked pieces of research have also been published, contributing to the growing body of work demonstrating that Kaupapa Māori approaches to Hapū Ora provide potential solutions to the current issues within the health systems providing care for whānau (Curtis et al. 2019; Tipene-Leach and Abel 2019; Pihama et al. 2019; Simmonds 2017). The current paper is not a review of all Kaupapa Māori research published. In addition to this there are other Māori scholars and Māori-led research contributing to other bodies of work (Pitama et al. 2007; Cormack et al. 2020; Pitama et al. 2020; Cram 2021; Cram et al. 2021b; Jones and Jenkins 2008). This paper has focused on a particular collection of work carried out in partnership, focused on strengths-based action research, and does not cover the wider field. There are also other areas not yet explored for the future and ongoing mahi.

Important subjects, such as terminations of pregnancy, stillbirth and fetal loss, which are a part of Hapū Ora, are not discussed here. It is important to recognise their impact for whānau and acknowledge the limitations of this paper to encompass these topics. All of these areas are important for health and wellbeing of whānau and cannot be done justice given the limits of this paper. Other very important Mātuaranga Māori concepts, such as whenua (land, placenta) and its relationships between the call to action, land and whānau, are not discussed in this paper. These are very important concepts that are challenging to do justice to within the scope of this paper and mahi.

Future research

Knowledge gained from each piece of research informs subsequent projects and programmes of work that seek to benefit iwi and indigenous communities. Future research areas include iwi-based maternal child health models (2022–25 project, Health Research Council 21/820) and whānau oral health care and Hapū Ora (publication in draft). The wero to all researchers is to ensure that all future Māori wāhine, pepī and whānau research is in keeping with Kaupapa Māori principles and is done by, with and for Māori.

Conclusion

These Kaupapa Māori and Māori-led research projects, and the international calls to action, challenge the status quo and provide opportunities for transformational change now. They provide a commentary and an outline of learnings that support preconception, Hapū Ora and the first 1000 days through Kaupapa Māori research approaches – highlighting what disrupts and what strengthens health and wellbeing. Ka whiua te taki – we lay the challenge down – to all non-indigenous and indigenous health practitioners, decision-makers, and researchers, to transform our current systems to improve wellbeing for whānau. The current statistics that come from the experiences of colonisation and racism must not continue. It is unacceptable that this continues. This body of research provides a platform on which change can occur. Action is needed! Change is needed!

Disclaimer

The views expressed in the submitted article are our own and not an official position of the institution.

Dissemination of results

Technical information will be disseminated via peer review publication, conference presentations, and funder reports.

Authors’ contributions

Reviewing of manuscript for intellectual content: all authors. All authors agreed on the final paper for publication. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Each study described here has undergone full ethical review and peer review processes prior to publication.

Acknowledgements

The authors wish to acknowledge the contribution of the pēpi (babies) and their whānau (families) who have contributed to this research.

Disclosure statement

The authors report there are no conflicts of interest to declare.

Data availability statement

The data that support the findings of the studies reported here are not publicly available.

Additional information

Funding

Individual studies described in the paper have received funding from various sources outlined in the publications listed.