INTRODUCTION
In Aotearoa New Zealand, it is estimated that one in four women experience a pregnancy that ends in whakatahe (miscarriage) within the first 20 weeks’ gestation; and that more than 95% of all miscarriages occur in the first 12 to 14 weeks of the pregnancy (College of Midwives, n.d.). In some cases, the miscarriage is spontaneous and complete, and in others a surgical procedure is required to remove what is called in medical terms “retained products of conception” (College of Midwives, n.d.). In the tertiary hospital, the context for this quality improvement initiative, when a surgical procedure is required, the woman is admitted acutely to hospital and cared for pre- and post-operatively by the registered nurses who work in the ward. Registered nurses are also responsible for the care of women admitted to the ward for labour to be induced due to a missed or delayed miscarriage. The woman’s midwife, if they have one, may have referred the woman to the hospital for diagnostic tests and treatment (New Zealand Government, 2021), or would otherwise normally be notified of the admission. However, hapū māmā (pregnant wāhine Māori) are less likely than non-Māori to have a midwife in their first trimester (Dixon, 2014).
A miscarriage is defined in law, under the Births, Deaths, Marriages, and Relationships Registration Act, 2021 as “the issue from its birth mother, before the 21st week of pregnancy, of a dead foetus weighing less than 400g” (Section 4). Miscarriage is a non-notifiable event partly because conception can end so early that pregnancy is not recognised, but also because under Section 4 of the Act, a miscarriage is not defined as a birth. Incidence data is therefore not collected nationally. However, fertility rates for wāhine Māori are higher than for non-Māori and pregnancy outcomes tend to be worse due to greater exposure to adverse socio-economic circumstances (Dawson et al., 2022; Fanslow et al., 2008). Consequently, wāhine Māori are more likely than non-Māori to need a surgical procedure due to an incomplete miscarriage, or for labour to be induced due to a missed miscarriage. While there appears to be no published evidence about the experience of wāhine during whakatahe, we know internationally, that women’s experiences of early pregnancy loss are largely negative, with their needs for emotional support not being met by healthcare providers (Freeman et al., 2021). Health services in general fail to provide adequate and appropriate healthcare for Māori (Espiner et al., 2021; Waitangi Tribunal, 2023). So in this highly medicalised context, the cultural needs of wāhine Māori are often overlooked. Indeed, the initial inspiration for this quality improvement project arose from a woman who expressed her concerns to the first author (AM) about her unmet cultural needs during her hospitalisation for whakatahe.
The clinical care of women admitted to hospital following miscarriage is guided by organisational policy documents. The hospital in which the first author works (AM) does have a clinical practice guideline that provides a clear procedural management pathway for miscarriage. Although the guideline has information about the services provided by Whānau Care Services, it has little content about tikanga Māori (traditional cultural practices) during miscarriage other than to encourage staff to initiate or facilitate karakia (prayers, chants) with women who identify as Māori. A recent internal survey of ward nurses by the first author (AM) about their knowledge of tikanga Māori highlighted poor knowledge, as well as poor understanding of cultural safety more broadly. None felt comfortable about initiating karakia.
The organisation ensures that all staff are exposed to a one-off education session about tikanga Māori principles as part of a generic orientation day. All nursing staff then complete an e-learning module within the first weeks of employment. There are no refresher courses. Registered nurses who complete their undergraduate degree in Aotearoa New Zealand develop an understanding of tikanga Māori and how it is underpinned by Te Tiriti o Waitangi during their study (Nursing Council of New Zealand, 2020). The increasing reliance, however, on internationally qualified nurses (44.7% of the nursing workforce at the time of writing; Nursing Council of New Zealand, 2024) who may have little experience of cultural safety or exposure to tikanga Māori means that tikanga principles in the context of inpatient miscarriage are rarely practiced.
Within traditional Māori society, tikanga was used to preserve the sacredness of childbirth. They were seen as protective measures for both mother and child, and supported restoration and healing (Mead, 2016). However, the current clinical practice guideline is representative of the biomedical, problem-based model of care prevalent in Aotearoa New Zealand’s healthcare system. Wilson et al. (2021) argue that the biomedical paradigm is contradictory to the holistic and relational worldview of health and well-being inherent to Māori perspectives. Hospitals, according to Māori accounts, evoke stress, alienation, anxiety, and discomfort for patients and their whānau, leading to mistrust in the services provided (Komene et al., 2024; Wilson et al., 2021). In many instances, Māori perceive hospitals not as health environments, but as spaces where their cultural, spiritual beliefs and practices are marginalised and overlooked (Espiner et al., 2021; Wilson & Barton, 2012). There is therefore an urgent need for meaningful attention to the cultural needs of wāhine Māori during inpatient experiences associated with miscarriage.
To that end, a quality improvement project was initiated in 2023 with the aim of incorporating elements of tikanga Māori principles and practices relevant to miscarriage into the clinical practice guideline used in a tertiary hospital ward following a miscarriage of pregnancy less than 21 weeks’ gestation. The project objectives included identifying and addressing gaps in the provision of culturally safe care during inpatient miscarriage for wāhine Māori and whānau by:
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Reviewing current organisational and ward specific documentation in relation to tikanga Māori
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Identifying tikanga Māori principles and practices about miscarriage reported in the literature
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Consulting with Māori midwives
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Applying the findings to Te Whare Tapa Whā framework (Durie, 1985)
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Establishing a plan for nursing staff to increase their knowledge and confidence initiating tikanga Māori practices.
DESIGN
A kaupapa Māori approach informed the project design. Kaupapa Māori is a research paradigm that prioritises whanaungatanga (kinship, a relationship through shared experiences) and is undertaken by Māori, to benefit the outcomes of Māori (Lawton et al., 2013). Within the time and resource constraints, Kaupapa Māori approaches were Māori-centred throughout the project in the following ways:
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The project concept was designed in collaboration with the charge nurse manager (Ngāti Porou) with a shared goal of increasing cultural awareness on the ward
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Māori midwives (Ki Tahu) and iwi (Ngai Tahu) were consulted
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Input was requested from the hospital cultural team
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Priority was given to knowledge, research, and data developed by Māori
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The project aimed to benefit wāhine Māori
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The outcomes were developed using the Te Whare Tapu Whā framework of holistic health.
DATA COLLECTION
Policy review
An analysis of organisational policies was conducted to review how tikanga Māori during the loss of pregnancy was addressed. The Te Whatu Ora (Health New Zealand) search programme “District Docs” was used to locate relevant documents. Organisational information, information sheets, clinical guidelines and clinical forms that related specifically to pregnancy loss less than 21 weeks’ gestation were accessed. Only clinical documentation created and used within the hospital was used in the review. Documents were assessed for relevant content about tikanga Māori, cultural safety, and contained links to external websites to further information about tikanga Māori.
Literature Review
A search for scholarly articles was undertaken using the Proquest, PubMed and Scopus databases. Few results that addressed tikanga Māori principles specific to miscarriage were found, although literature related to birthing and tangihanga (funeral) were more plentiful. During the search, we came to understand that the birthing and tangihanga literature was also applicable to whakatahe and that the tikanga principles were largely the same. Advice from a subject librarian was to include podcasts and personal blogs. While not formal scholarly sources, they provided authentic and diverse perspectives of the experience of wāhine Māori that both guided and enriched the project outcomes.
Consultation with Māori midwives
With support from members of the first author’s iwi, contact was made with “Ki Tahu Midwives” and a number of their Māori midwifery students. This organisation focuses on Māori customs during pregnancy and birth and have supported the integration of tikanga Māori practices into their local hospitals and birthing suites. Emails and Zoom calls were the main method of contact.
There was no response to the requests for input from the hospital’s cultural team.
FINDINGS
Policy review
A total of 12 documents were analysed to evaluate whether tikanga Māori had been addressed. Of these documents, seven were patient information sheets. Five were a combination of clinical guidelines and inpatient forms. There was a notable absence of tikanga Māori principles in any of the documents. Three of the organisational documents touched on Māori cultural safety but only advised of the services provided by Whānau Care Services. Cultural safety and Māori were searched for specifically due to a number of policies that included cultural information about religion and gender. Seven of the documents reviewed had links to external websites with information about tikanga Māori principles and pregnancy loss. Three of the policies had no cultural recommendations and lacked links to external information.
Literature review
Amongst Māori, the word ‘pēpi’ is used irrespective of gestational age and refers to an infant both before and after its birth. Accordingly, the cultural approach to the death of pēpi is unaffected by gestational age (Jutel, 2006). Traditionally, the pēpi is perceived to have wairua (spirit/soul). Should the pregnancy cease, the pēpi is said to embody a spirit. The spirit, known as utu, is believed to arise as a result of pēpi failing to gain human existence. The spirit is said to manifest through pain, grief and illness and requires timely karakia (Tupara, 2017).
Acknowledging the diverse and rich variation in tikanga Māori traditions between iwi, hapū, and whānau, eight concepts associated with pregnancy, birthing, or whakatahe were identified in the literature and are outlined in the following section. Each concept is briefly explained. Readers should remain mindful that miscarriages requiring medical intervention in an inpatient setting are more complex than those that occur in the community. Some tikanga practices, such as the use of muka (flax) ties, whenua ki te whenua (return of the placenta to the earth), and the use of ipu (container) can apply only if pēpi and/or whenua are delivered intact. Their use is also dependent on the wishes of whānau.
Tapu
The notion of tapu (meaning sacred, prohibited) holds a pivotal place in Māori existence, particularly in the context of pregnancy and birth. After conception, wāhine enter a state of tapu that provides a safeguard against potential health risks (August, 2005). As the birth approaches, the state of tapu intensifies and the wahine may isolate herself from the community to a whare kōhanga, a purpose-built birthing shelter. A unique whariki (mat) was woven and served as the foundation for the birthing wahine (Tupara, 2017). During the birthing process, wahine might squat, braced by the knees of a birth attendant who was similarly positioned (Le Grice & Braun, 2016), or stand at a pou (a sturdy pole) for support (Berryman et al., 2022), and mirimiri (massage) might be used to ease pain and tension (Barrett et al., 2024).
Karakia
Karakia serves has both spiritual and cultural roles during birth. It is recited to invoke spiritual guidance and protection, providing a sacred and supportive birthing environment. Birth is seen as a holistic event that involves the spiritual realm as much as the physical. Karakia is used to call on the atua (gods), usually Hineteiwaiwa (spiritual guardian of childbirth), to seek the blessing of deities and connect with ancestors, promoting a harmonious birthing experience (Berryman et al., 2022).
Waiata and Oriori
During the birth of pēpi, both waiata (song) and oriori were sung. Oriori is a unique and sacred waiata that is traditionally composed for each pēpi (Royal, 2021; Tupara, 2017). It served as a narrative, recounting the unique story of the birth of pēpi and their whakapapa. Oriori holds additional significance because it is also sung following the loss of a child (Hākui, n.d.). It is an expression of aroha (love) and can be heard at tangihanga, symbolising a heartfelt acknowledgment of the lineage, whakapapa and mana of the tūpāpaku (deceased). Traditionally, oriori was sung by the wider whānau, tohunga (appointed spiritual leader) and kaumātua (elder). It reinforced the spiritual nature of mokopuna (descendants) and their links to the atua. Oriori helps calm the birthing mother by inviting her to breathe and move through the rhythmic chants (Tikao, 2023).
Tohunga
During birth, a tohunga assumed a distinct role as an appointed spiritual leader. They provided assistance with the challenges of birth through karakia, offered support and facilitated the birthing process. Their involvement also extended to post-birth ceremonies, connecting pēpi with deities through water rituals (Mead, 2016).
Whānau
The inclusion of whānau and the wider hapū (tribe) during childbirth was common practice (Manihera, 1990). Whānau engaged in performing waiata, oriori and reciting karakia. In the context of hospitals, however, whānau often experience the environment as hostile to cultural practices (Espiner et al., 2021). Following the birth, a kaumātua (a person of status within the whānau) would be the first to touch pēpi. This act was to affirm pēpi’s heritage and ensures the immediate acknowledgement and passing on of their whakapapa (Mead, 2016).
Muka ties
Muka are woven ties made from harakeke (flax) fibre and tied around the umbilical cord (pito). Muka were traditionally tied by pāpā and māmā tuarua (grandparents or secondary caregivers), establishing a connection with their tūpuna (ancestors, elders). The muka ties along with the dried pito are later returned to the whenua in an ipu pito (umbilical container) (Barrett et al., 2024; Mead, 2016; Te Huia et al., 2023).
Whenua ki ti whenua
The placenta was buried following the birth, symbolising the link between the past and present. That is, the placenta that provided nourishment to the pēpi can now provide nourishment to the land for tāngata whenua (people of the land). Returning the placenta is a way to honour this connection and maintain whānau ties to their ancestry, spirituality and identity (Le Grice & Braun, 2016; Manihera, 1990; Mead, 2016).
Tikanga following death
Following death, the tūpāpaku is considered sacred and is not to be left alone. Although the wairua has left the tūpāpaku, it is said to stay close by until the tangihanga practices take place (Higgins & Moorfield, 2004). The room that housed the tūpāpaku is cleaned after the tūpāpaku is removed, and karakia are said as part of the cleansing ritual, as is the sharing of kai (food). Thus, the space moves from one of tapu to noa (ordinary, not sacred) (Moeke-Maxwell et al., 2019).
Traditional birthing practices used by Ki Tahu Midwives
The increasing awareness and eagerness of whānau Māori to return to their natural birthing processes was evident during discussions with Ki Tahu midwives. They reported a growing interest amongst Māori whānau to incorporate mātauranga tīpuna (Māori knowledge systems) into their birthing journey. It was clear to these midwives that entirely clinical approaches to communication with hapū wāhine leads to disengagement from healthcare services. In their practice, the midwives sought to minimise the impact of medicalised birthing (including miscarriage) by reconnecting wāhine Māori with traditional practices that support safety and protection. They used and recommended simple te Reo (Māori language) during conversations, such as:
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Pēpi rather than “foetus” or “products of conception”
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Whenua rather than placenta, which is not a term commonly used by Māori
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Whakawātea which refers to the act of clearing, symbolising cutting the umbilical cord.
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Whakatahe can be used in place of miscarriage, pregnancy loss, or termination of pregnancy.
The midwives offer hapū wāhine the opportunity to provide their own ipu whenua, which is used to house the placenta for the practice of whenua ki te whenua tikanga (return of the placenta to the earth). Traditionally, ipu whenua were made from harakeke (flax) but more recently, wāhine create ipu whenua from clay, wood, or used meaningful organic fabrics. Ipu whenua now replace the hospital’s specimen containers previously used to store placentas which looked much like plastic ice cream containers.
Plastic cord clamps are no longer used and traditional muka ties are used instead. The change has led to a noticeable reduction in omphalitis (umbilical cord infection), although there is not yet research to support the midwives’ observation. Another advantage of muka ties is that they decompose and can be buried with the pito. Most of the ties used by the midwives are donated by weavers from the iwi but they were also available for purchase online from certified Māori businesses.
In Māori culture, the presence of whānau is a highly valued support during birthing (Espiner et al., 2021). Yet the midwives were aware that many hapū wāhine had been opting for a home birth, primarily due to limitations on visitors in hospitals and birthing suites. A crucial early step for the establishment of a successful traditional midwifery practice in hospitals and birthing suites had been to actively support unrestricted visitor access.
During both birth and pregnancy loss, the midwives encourage whānau to participate in karakia and waiata. Oriori was also seen as beneficial because it involved the wider whānau, increasing its protective properties. However, these practices have posed many challenges for the midwives because hospitals often prioritise a quiet environment over tikanga.
Following whakatahe, providing a dedicated space for whānau to spend time with pēpi and be together to comfort and support each other is essential. Having an additional separate space for kai to be consumed is tika (correct) and acknowledges the tikanga associated with tapu and noa during this time.
Applying tikanga to practice using Te Whare Tapa Whā framework
We have taken the findings about tikanga from the literature and the advice from the Ki Tahu midwives and applied them to practice using the well-known Māori model of health, Te Whare Tapa Whā (Durie, 1985). The model presents a Māori perspective of good health as a wharenui (meeting house). Each of the four walls represent spiritual, mental and emotional, physical, and whānau aspects of health and wellbeing, with the land symbolising the connection between Māori and the land. When all aspects are in balance, good health is achieved (Wolfgramm et al., 2020). Tikanga principles and their clinical application following miscarriage are presented in Table 1. Collectively, these actions contribute to an improved health service experience for the māmā and whānau.
PROJECT OUTCOMES
There were many recommendations for change arising from this project, but the issue with the highest priority was to increase the knowledge and confidence of nurses to incorporate tikanga Māori into their everyday practice when caring for wāhine during whakatahe. A specific study day for nurses about the fundamentals of tikanga Māori has been developed. The project findings have been discussed at senior nurses’ meetings and presented at a hospital-wide clinical forum. The majority of senior nursing staff were unaware of the lack of tikanga principles in the hospital’s procedures and processes. Many were unaware that registered nurses rather than midwives were responsible for the care of wāhine during miscarriage.
Basic education about the fundamentals of tikanga Māori principles and processes with nursing staff on the ward has led to meaningful change. Nurses now orient whānau to the ward, showing them the whānau rooms and explaining their purpose. They provide information about visiting times and promote open visiting during those hours. Nurses ensure that whānau know that their room is their own space where they can sing waiata and recite karakia without fear of being asked to be quiet. Other changes observed include the installation of doors on the nurse’s station, ensuring a quiet space for wāhine and their whānau to carry out karakia. Nurses seem more at ease about supporting whānau to grieve in a manner that suits their cultural and emotional needs. When appropriate, whānau are now encouraged to provide muka ties and ipu which are used in preference to cord clamps and hospital containers.
Another noteworthy outcome of this project and subsequent education, is a shift in practice concerning how pēpi are cared for after the delivery. Formerly, pēpi were removed to the sluice room to be washed and dressed and then returned to the room. Now, with better understanding of tikanga Māori, these activities take place in the bedspace with whānau involvement, and a wahakura (a woven flax bassinet) is available for pēpi.
CONCLUSION
This Quality Improvement project has shown the enduring relevance of hauora Māori principles and practices and the feasibility of their use in a modern healthcare setting. There is, however, a need for research about opportunities for appropriate tikanga to be applied and practised in other clinical contexts. The project began by noticing the paucity of information about tikanga Māori in the context of inpatient miscarriage in policy, clinical practice guidelines and patient information. The literature identified distinct birth-related tikanga Māori principles and practices that are beneficial for whānau Māori during inpatient miscarriage. Insights gathered from conversations with Ki Tahu Midwives affirmed the feasibility of integrating tikanga Māori practices into a healthcare environment.
Importantly, the project findings point to a readily achievable solution requiring only investment in the education of nurses in tikanga Māori, along with their commitment to learn and develop the confidence to use their knowledge to support wāhine Māori and whānau during a time of loss and grief. As nurses learn and apply tikanga principles to their practice they role model and share their learning with colleagues. The challenge ahead is to build on what has been learned and sustain the changes made by embedding tikanga Māori into normal, everyday practice, and to revise the policy documents.
Finally, this project has endeavoured to support holistic health outcomes across all dimensions of the Te Whare Tapu Whā framework. While contemporary medicine prioritises physical wellbeing, many Māori find this approach overlooks wairua, the importance of whānau involvement, and the balance of hinengaro. Each of these dimensions are significant and this initiative has highlighted that it is possible for nurses to work in partnership with whānau and to improve the experience of health services for wāhine Māori.
Acknowledgement
Our thanks to Ngāi Tahu whānau for your support and advice throughout the project. Our thanks also to Ki Tahu Midwives and Otago Polytechnic midwifery students for sharing your practice wisdom and aroha. We are especially grateful to the nurses on the ward, the Charge Nurse Manager, and Clinical Nurse Specialist, for your willingness to embrace this kaupapa. Aroha nui.
Funding
None
Conflict of interest
None