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Māori mothers have the right to breastfeed their infants. This is recognised in the United Nations (UN) Convention on the Rights of the Child,[[1]] and the right to traditional practices in the UN Declaration on the Rights of Indigenous Peoples[[2]] and the Treaty of Waitangi.[[3]] For Māori, tamariki (children) are taonga (treasured), and breastfeeding is tika tūāpapa (a fundamental right). Within Te Ao Māori (Māori worldview), breastfeeding is a fundamental aspect of tikanga Māori (Māori cultural traditions/practices) that needs to be protected and promoted.[[4]] Breastfeeding for wāhine Māori (Māori women) is a tikanga informed by mātauranga Māori (Māori knowledge) accumulated from generations of whakapapa (Māori genealogy).

Exclusive breastfeeding is beneficial short-term and long-term to both infant and mother.[[5]] Exclusive breastfeeding for six versus four months protects against gastroenteritis and promotes maternal amenorrhea and weight loss.[[6]] Breastfeeding also has economic and environmental benefits.[[7]] The New Zealand Ministry of Health[[8]] and the World Health Organization (WHO),[[9]] recommend exclusive breastfeeding for six months. The 2025 Global Nutritional Target is exclusive breastfeeding for 50% of children under six-months-old.[[10]] Despite this, exclusive breastfeeding rates in high-income countries remain low.[[5]] In Aotearoa New Zealand, while breastfeeding initiation is almost universal (97%), only 16% of children are exclusively breastfed to age six months.[[11]]

Determinants of breastfeeding initiation relate to immediate medical and social supports.[[12]] However, this is not the case for exclusive breastfeeding duration, with various economic, political, historic and cultural factors; social and health professional supports; and individual biopsychosocial factors involved.[[5,12]] Different factors affect different peoples and hence there are strong recommendations for country- and culture-specific research to inform practice and policy.[[6]]

One New Zealand qualitative study identified five ways to improve exclusive breastfeeding for Māori: (i) smoking cessation during pregnancy; (ii) breastfeeding guidelines aligned with Māori beliefs; (iii) guidelines emphasising breastfeeding benefits to mother and child; (iv) education on fertility, bed-sharing and tobacco in regard to breastfeeding; and (v) healthcare provider recognition of the social and cultural circumstances for Māori mothers and whānau (family).[[4]] In another study with predominantly Māori participants, increased breastfeeding duration was associated with partner and whānau support at one month post-partum, intention to breastfeed and being an older mother.[[13]] Decreased breastfeeding duration was associated with pacifier use, cigarette smoking, alcohol use, and household deprivation.[[13]]

To address the limited contemporary data on exclusive breastfeeding for Māori women, this study aimed to identify independent determinants of exclusive breastfeeding for six-or-more months for Māori women enrolled in Growing Up in New Zealand (GUiNZ).[[14]] In this study, analyses followed a contemporary Māori model of health and wellbeing developed by Māori researchers specifically for the GUiNZ Māori cohort. This research will inform future interventions to protect, promote and support Māori in exclusive breastfeeding.

Methods

Study design and setting

We completed this study within New Zealand’s contemporary child cohort study, Growing Up in New Zealand (GUiNZ, www.growingup.co.nz). GUiNZ study design and cohort profile are described elsewhere.[[14]] Approximately 30% of the Māori population of New Zealand reside in the study region, with 9% of Māori women who gave birth in New Zealand during the recruitment period enrolled.[[15]] The New Zealand Ministry of Health Regional Ethics Committee granted ethical approval and all study participants provided written informed consent.

Study population and sample

GUiNZ recruited 6,822 pregnant women and their 6,853 children.[[14]] At enrolment, women identified all ethnic groups to which they belonged. This study limited the sample to the 1,060/6,822 (16%) pregnant women who self-identified Māori as one of their stated ethnicities, had singleton births and provided information on exclusive breastfeeding duration at nine-month interview.

View Figure 1.

Data collection

GUiNZ collected information in six interconnected domains: health and wellbeing; psychosocial and cognitive development; education; family and whānau; culture and identity; and social context, neighbourhood and environment, with a Māori theme running across all domains.[[14]] The Māori theme and kaitiaki (guardianship) advisory group allow for the examination of factors contributing to the wellbeing of tamariki Māori and their whānau over time.[[14]]

Data were collected antenatally; perinatally; when the infant was six weeks old and nine months old. Mothers were interviewed face-to-face or via telephone as described.[[14]] Linkage to birth records occurred via each child’s National Health Index (NHI) number, a unique identifier assigned to each person in New Zealand at their first contact with the New Zealand healthcare system.

Exclusive breastfeeding duration

The WHO define exclusive breastfeeding as receiving only breastmilk (including expressed milk) and not any water, milk formula, other liquids, or solid food; but with medicines, vitamins and minerals allowed.[[10]] Maternal recall overestimates exclusive breastfeeding duration. Therefore, we used maternal recall adjusted for age of first food introduction to describe exclusive breastfeeding duration.[[11]]

Te Anga o ngā Horopaki Māori: a conceptual framework for considering Māori lived realities

This study framed analyses within a conceptual model of health and wellbeing for contemporary Māori lived realities (circumstances and environments), developed specifically for Māori participants of GUiNZ. Te Anga o ngā Horopaki Māori draws on Sir Mason Durie’s Te Whare Tapa Whā,[[16]] and other Māori models of health and wellbeing (Meihana,[[17]] Te Wheke[[18]] and Ngā Pou Mana[[19]]) to inform its design and represent contemporary Māori perspectives of health and wellbeing. Te Whare Tapa Whā conceptualises health holistically as the four sides of a whare (house): taha wairua (spiritual), taha hinengaro (thoughts and feelings), taha tinana (physical) and taha whānau (family and community relationships).[[16]] In collaboration with Te Puni Kōkiri, the framework was aligned with current Māori policies and health strategies.[[20]] Te Anga o ngā Horopaki Māori comprises six interconnected domains: Mahi Arataki (Policy and strategy); Te Ao Māori (Cultural identity); Whai rawa (Economic resources and capability); Taiao a hapori (Environment and community); Whanaungatanga (Family and home); and Hauora (Health and wellbeing) (Figure 2; see Appendix 1 for a description domains and associated assessment tools and measures). Te Anga o ngā Horopaki Māori allowed us to consider a range of factors related to exclusive breastfeeding within a context aligned with Māori perspectives of health and wellbeing.

View Figure 2.

Study power and sample size

GUiNZ recruited 6,822 pregnant women and their 6,853 children.[[14]] This study size provided adequate statistical power to undertake complex analyses of interwoven developmental trajectories over time, in the whole cohort and within subgroups of children identifying as Māori, Pacific and Asian ethnicity.[[14]] Study power calculations for GUiNZ were based upon the study being specifically designed to have adequate explanatory power for the main ethnic groups in New Zealand, with the assumption then that study power for the whole cohort would be adequate. For example, a sample size of 1,000, which was exceeded by each of the four main New Zealand ethnic groups at enrolment (NZ European n=4,237; Māori n=1,246; Pacific n=1,151; Asian n=1,074)[[21]] has 80% power at the 0.05 level of significance to detect a relative risk of 2.1 for an outcome which is found in 10% of the unexposed population if 10% of the population is exposed, and 80% power at the 0.05 level of significance to detect a difference of approximately 0.4 standard deviations between the exposed and unexposed group, if 5% of the population is exposed.[[22]] In this study, of the 1,060 wāhine Māori who had singleton births and provided information on exclusive breastfeeding duration at nine-month interview, we had sufficient power to investigate exposures affecting at least 10% of the cohort with an associated increased odds in outcome that is generally considered both statistically and clinically significant.

Data analyses

Te Anga o ngā Horopaki Māori and literature review identified variables potentially associated with exclusive breastfeeding duration. Associations with exclusive breastfeeding duration were determined using the Chi-square test for proportions, and the t-test or Wilcoxon Rank-Sum test for normally and non-normally distributed continuous variables, respectively.

Variables were included in the multivariate model when P<0.20, or if they were significant in published studies, or were important in describing each domain within Te Anga o nga Horopaki Māori. We constructed the multivariate model hierarchically: beginning with the domain most distal to the mother and infant (Mahi Arataki) and adding individual variables stepwise towards the most proximal (Hauora) domain (Figure 1). Variables were retained for subsequent analysis steps if P<0.20. If no variables in a domain had P<0.20 then the variable within each domain with the lowest P value was retained for the remainder of the analyses. Independent associations with exclusive breastfeeding duration of six-or-more months were determined using multivariable logistic regression, and described using adjusted odds ratios (aOR) and 95% confidence intervals (CI). SAS 9.4 (Cary, NC, USA) was used for all analyses.

Results

Study population and sample

Wāhine Māori comprised 1,260/6,822 (18%) of the GUiNZ cohort (Figure 1). This study was limited to the 1060/6822 (16%) wāhine Māori who had singleton births and provided information about breastfeeding when their infant was nine months old.

Breastfeeding in wāhine Māori

Overall, 6,083/6,274 (97%) pregnant women reported breastfeeding their child. Almost all wāhine Māori initiated breastfeeding (1,068/1,117; 96%), as did non-Māori women (5,014/5,156; 97%) although these differences were statistically significant (P=0.004) (Table 1). However, 132/1,060 (12%) wāhine Māori and 868/4,972 (17%) non-Māori breastfeed for six-or-more months (P<0.001) (Table 1). Median (interquartile range [IQR]) exclusive breastfeeding duration was 3 (2–4) months for wāhine Māori and 4 (2–5) months for non-Māori (P<0.001).

View Table 1.

Identification of variables for hierarchical logistic regression modelling

Preliminary analyses within Te Anga o ngā Horopaki Māori revealed 32 variables potentially associated with exclusive breastfeeding in wāhine Māori. Each variable was situated within one of the six interconnected Te Anga o ngā Horopaki Māori domains: Mahi Arataki (Appendix 2); Te Ao Māori (Appendix 3); Whai Rawa (Appendix 4); Taiao a Hapori (Appendix 5); Whanaungatanga (Appendix 6); and Hauora (Appendix 7).

Characteristics associated with exclusive breastfeeding in wāhine Māori

Hierarchal logistic regression analyses consisted of sequential steps within Te Anga o ngā Horopaki Māori as described (Methods; Supplementary Figure 1). The final model included 17 variables, with at least one variable from each Te Anga o ngā Horopaki Māori domain (Table 2). Based on these analyses, six variables in four Te Anga o ngā Horopaki Māori domains were independently associated with exclusive breastfeeding for six-or-more months.

Within Mahi Arataki, wāhine Māori were more likely to exclusively breastfeed for six-or-more months, if they had thought, antenatally, that it was best to breastfeed for longer than six months (aOR=1.94, 95% CI 1.05–3.78) versus up to six months. Wāhine Māori who thought their breastfeeding duration would not be limited (aOR=2.17, 95% CI 1.17–4.24) or may be limited (aOR=4.25, 95% CI 1.86–9.85) by their return to work were more likely to exclusively breastfeed for six-or-more months, compared with mothers who thought their breastfeeding duration would be limited by their return to work.

Within Te Ao Māori, wāhine Māori who rated maintaining cultural traditions and practices as “fairly important” (aOR=0.53, 95% CI 0.27–0.99) were less likely to exclusively breastfeed their infant for six-or-more months, compared with women who rated these as “very important”.

Within whanaungatanga, experienced Māori mothers (aOR=2.55, 95% CI 1.35–5.06), compared to first-time mothers, were more likely to exclusively breastfeed for six-or-more months.

Within Hauora, mothers who experienced depression during pregnancy (aOR=0.47, 95% CI 0.20–0.99) were less likely to exclusively breastfeed their infant for six-or-more months than those without depression symptoms. Mothers who remained undecided about their child’s infant immunisations (aOR=3.16, 95% CI 1.55–6.39) were more likely to exclusively breastfeed for six ormore months than mothers who had decided about immunisation.

View Table 2.

Discussion

In this contemporary cohort of New Zealand mothers, breastfeeding initiation was almost universal with 96% of wāhine Māori and 97% of non-Māori women initiating breastfeeding. Yet exclusive breastfeeding rates remain poor, with 17% of non-Māori and 12% of wāhine Māori exclusively breastfeeding their infants for the recommended six months. Therefore, significant improvement in exclusive breastfeeding rates is needed for New Zealand to achieve the Global Nutrition Target for 2025 of 50% of infants under six months old exclusively breastfeeding.[[10]]

The New Zealand Ministry of Health and WHO recommend exclusive breastfeeding for six months followed by continued breastfeeding with complementary foods up to two years old.[[8,10]] When Māori mothers’ breastfeeding beliefs aligned with these recommendations, they were more likely to exclusively breastfeed for six-or-more months. Mothers often decide about breastfeeding prior to or early in pregnancy,[[24]] and access to high quality breastfeeding information can inform their decision-making.[[25]] Māori mothers and grandmothers also highlight breastfeeding role models, whānau support, culturally safe healthcare, and wider community acceptance of breastfeeding, all as important for supporting breastfeeding.[[25]] Whānau are central to breastfeeding decision-making and support.[[26]] Public health policies that encourage delivery of high quality breastfeeding information to wāhine Māori and whānau in a culturally safe, accessible and effective way are important for promoting and supporting breastfeeding and whānau ora (family health and development).

Analyses within Te Anga o ngā Horopaki Māori model of health revealed six determinants of exclusive breastfeeding for Māori mothers within four model domains. Although the Whai Rawa and Taiao a Hapori domains were unrepresented, the overlapping nature of domains within Te Anga o ngā Horopaki Māori means that variables from other domains (i.e., return to work and maintaining cultural traditions/practices) intersect with these domains.

Mothers’ return to work is well recognised as a determinant of exclusive breastfeeding duration,[[27]] and was identified as a major theme in qualitative analyses of breastfeeding barriers in wāhine Māori.[[28]] Paid parental leave in New Zealand increased from 13 weeks during the study period to 26 weeks in 2019.[[29]] The eligibility criteria have also broadened to include more casual workers. It is important to assess if this policy change has had a positive influence on Māori exclusive breastfeeding rates, and whether current policy supports Māori to access paid parental leave.

Wāhine Māori consider breastfeeding the natural, normal and Māori way to feed their pēpē (baby)[[30]] and a fundamental aspect of tikanga Māori.[[4]] Wāhine Māori in our study who rated maintaining cultural traditions and practices as “fairly important”, compared with very important, were slightly less likely to exclusively breastfeed their infant for six-or-more months, although this finding was not statistically significant. The legacy of colonisation, poverty, and systemic racism limits access to Te Ao Māori to a privileged few. Pākehā (European) colonisation of New Zealand profoundly impacted breastfeeding for Māori.[[30]] In pre-colonial times, Māori infants were breastfed by their mothers or other lactating women.[[31]] Western reframing of Indigenous knowledge and beliefs as myths and legends,[[3]] the Tohunga (traditional healer) Suppression Act (1907–1962) and the general, but erroneous, belief that there was a law preventing wāhine Māori from breastfeeding in public[[28]] combined to reduce Māori breastfeeding rates. Throughout the 20th century, the medicalisation of birth and the introduction of infant formula undermined the rich breastfeeding knowledge shared between women, particularly wāhine Māori, leading to a significant decline in breastfeeding rates.[[32]] Contemporary Māori mothers report professional insensitivity and conflicting advice about breastfeeding as contributing to lack of confidence in healthcare providers.[[30]]

Mothers who experience depression during pregnancy are less likely to initiate breastfeeding, and more likely to cease exclusive breastfeeding before six months.[[33]] We found that Māori mothers who experienced depression during pregnancy were less likely to exclusively breastfeed for six-or-more months. There is also evidence that early cessation of breastfeeding is a risk factor for maternal anxiety and depression.[[34]] Together, these findings highlight the importance of routine perinatal depression screening, and of providing culturally safe breastfeeding and mental health support to Māori mothers exhibiting depression symptoms.

Previous studies have identified smoking as a barrier to exclusive breastfeeding for Māori mothers.[[4,13]] One-third of mothers in our study reported smoking during pregnancy; however, the association between smoking and exclusive breastfeeding was excluded from our final model. When included in the model, there was no significant association between smoking and exclusive breastfeeding (results not shown).

We found that Māori mothers with more than one child were more likely to exclusively breastfeed for six-or-more months than first time mothers, similar to findings for the whole GUiNZ cohort and other studies.[[11,35]] Thus, first time Māori mothers may benefit from additional breastfeeding support from whānau, community and healthcare providers.

According to WHO, vaccine hesitancy is one of the top ten threats to global health. Hesitancy is due to a combination of a lack of confidence in the vaccine or healthcare provider; complacency towards the disease or the vaccine; and convenience or vaccine access.[[36]] Historically, there are multiple reasons for wāhine Māori to distrust infant nutrition recommendations from New Zealand healthcare providers. The message that breastfeeding strengthens the immune system may contribute to complacency with respect to immunisation.[[37]] Wāhine Māori report breastfeeding as tikanga Māori,[[30]] whereas immunisations are not reported in the same light.[[38]] Finances, time, geography, and cultural access, whereby vaccines are not promoted in line with tikanga Māori, are all important barriers to immunisation.[[39]] Addressing present and historic distrust of the health system and creating an environment where immunisation supports Māori perspectives of health and wellbeing may improve both breastfeeding and immunisation rates.

Antenatal recruitment with adequate explanatory power for analyses within the Māori cohort is a strength of our study.[[14]] Breastfeeding and food introduction were one of a number of domains about which study participants were questioned, therefore reducing the likelihood of reporting bias. A limitation of our study was maternal recall bias of exclusive breastfeeding; however, we minimised this by adjusting for the age of food introduction.[[11]] This study supports the use of Māori models of health in the quantitative analysis of exclusive breastfeeding, but acknowledges the limitations with exclusion of whānau responses.

Breastfeeding interventions aim to protect, promote, and support breastfeeding.[[40]] Protection is the most effective intervention in reducing inequities, occurs at a population level and involves legislation, regulations and policy. Policy directed at protecting breastfeeding in the workplace and public spaces must acknowledge historical wrongs Māori have faced, and must be centred on breastfeeding as tikanga Māori. To reduce inequities, legislation must include adequate enforcement of these policies, rather than relying on guidelines, and monitoring of breastfeeding must be representative of Māori. Recent improvements to parental leave provisions go some way to reducing inequities;[[29]] however not all mothers are eligible. Universal paid parental leave would provide breastfeeding protection.

Breastfeeding promotion should commence prior to or early in pregnancy and include mothers, whānau, health professionals and society as a whole.[[40]] Policy changes that provide kaupapa Māori pregnancy, childbirth and infant healthcare; increase Māori participation in midwifery and well-child care; and include whānau in healthcare decision-making are essential to improving outcomes for wāhine Māori and their pēpē.

Improving Māori health outcomes and honouring the principles of Te Tiriti o Waitangi are central components of current New Zealand health system reform.[[41]] The establishment of national entities, Te Mana Hauora Māori (Māori Health Authority) and Hauora Aotearoa (Health New Zealand), will change the way the health system understands and responds to Māori health needs, drive the provision of kaupapa Māori services and develop policy and strategy to improve health outcomes for Māori. Iwi–Māori Partnership Boards will be the primary source of whānau voice, will have decision-making roles at the local level, and will work with the national entities to determine local priorities and healthcare delivery. A whole of system approach to healthcare reform must address structural racism and empower tangata whenua and tauiwi (non-Māori) to fully engage in promoting health equity for Māori.

Conclusion

While most Māori mothers initiate breastfeeding, only a small proportion continue exclusive breastfeeding until their infant is aged six months. Determinants of exclusive breastfeeding in wāhine Māori are knowledge of breastfeeding recommendations, return to work, motherhood experience, connection to Māori cultural traditions/practices, antenatal depression, and vaccine indecision. Proposed New Zealand health system reforms aim to honour Te Tiriti o Waitangi principles and address the legacy of colonisation, poverty, and systemic racism on Hauora Māori. These reforms should allow the development of breastfeeding policy and interventions that acknowledge and redress the damage that breastfeeding policies have historically had on Māori. Interventions delivered within a kaupapa Māori framework will best address breastfeeding inequities in New Zealand. Health equity for Māori has the potential to improve health outcomes for all New Zealanders.

View Appendices.

Summary

The findings of this research can be used to inform future interventions to protect, promote and support Māori in exclusive breastfeeding. Aotearoa New Zealand is not meeting global nutrition targets for exclusive breastfeeding of infants until six months. While nearly all non-Māori women and wāhine Māori start breastfeeding, only 17% of non-Māori and 12% of wāhine Māori continue to exclusively breastfeed for the recommended six months. Breastfeeding is a fundamental aspect of tikanga Māori (Māori cultural traditions/practices) requiring protection and promotion. Interventions delivered within a kaupapa Māori framework will best address breastfeeding inequities in Aotearoa New Zealand. Mothers who felt that returning to work would limit breastfeeding were less likely to carry on exclusively until six months. Paid parental leave is currently six months, but this will only cover up to about five and half months of baby’s life, and not all women have access to paid leave.

Abstract

Aim

Breastfeeding is a fundamental aspect of tikanga Māori(Māori cultural traditions/practices) requiring protection and promotion. This studyidentifies determinants of exclusive breastfeeding in wāhine Māori (Māori women).

Method

Wāhine Māori enrolled in the Growing Up in New Zealand child cohort study participated (n=1060). Exclusive breastfeeding duration was self-reported. Hierarchical regression analyses were framed by a model of Māori health and wellbeing.

Results

Most wāhine Māori initiated breastfeeding (96%), with 12% exclusively breastfeeding for six- or-more months. Wāhine Māori had increased odds of exclusively breastfeeding for six-or-more months if they: thought it best to breastfeed for >6 months (adjusted odds ratio (aOR)=1.94, 95% confidence interval (CI)=1.05-3.78); thought returning to work would not (aOR=2.17, 95% CI=1.17–4.24) or may (aOR=4.25, 95% CI=1.86–9.85) limit breastfeeding; were experienced mothers (aOR=2.55, 95% CI=1.35–5.06); or were undecided about vaccination (aOR=3.16, 95% CI=1.55–6.39). Exclusive breastfeeding for six-or-more months was less likely if mothers experienced depression during pregnancy (aOR=0.47, 95% CI=0.20–0.99) or viewed cultural traditions/practices as “fairly important” (aOR=0.53, 95% CI=0.27–0.99), compared to “very important”.

Conclusion

Determinants of exclusive breastfeeding in wāhine Māori are knowledge of breastfeeding recommendations, return to work, motherhood experience, connection to Te Ao Māori (Māori worldview) and tikanga Māori, antenatal depression and vaccine indecision. Interventions delivered within a Kaupapa Māori framework will best address breastfeeding inequities in Aotearoa New Zealand.

Author Information

Denise Bennett: Paediatrician, General Paediatrics, Kidz First Hospital, Counties Manukau District Health Board, Auckland. Catherine A Gilchrist: Lecturer, Department of Paediatrics: Child & Youth health, The University of Auckland, Auckland. Rochelle L Menzies: Research Fellow, Koi Tū: The Centre for Informed Futures, The University of Auckland, Auckland. Matire Harwood: Associate Professor, Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland, Auckland. Te Kani Kingi: Professor, Te Mata o te Tau, Ngā Pae o te Māramatanga – The Academy for Māori Research and Scholarship, Massey University. Polly Atatoa Carr: Associate Professor, National Institute of Demographic and Economic Analysis, Faculty of Arts and Social Sciences, The University of Waikato, Hamilton; Growing Up in New Zealand, The University of Auckland, Auckland; Centre for Longitudinal Research – He Ara ki Mua, The University of Auckland, Auckland. Susan Morton: Professor and Director, Centre for Longitudinal Research – He Ara ki Mua, The University of Auckland, Auckland; Growing Up in New Zealand, The University of Auckland, Auckland. Cameron C Grant: Professor of Paediatrics, Department of Paediatrics: Child & Youth health, The University of Auckland, Auckland; Growing Up in New Zealand, The University of Auckland, Auckland; Centre for Longitudinal Research – He Ara ki Mua, The University of Auckland, Auckland; General Paediatrics, Starship Children’s Hospital, Auckland District Health Board, Auckland.

Acknowledgements

Most importantly, we would like to acknowledge the children and the families who are part of the Growing Up in New Zealand study. We would also like to acknowledge the initial funders, in particular the New Zealand Ministry of Social Development, supported by the Health Research Council, as well as the ongoing support from Auckland UniServices and The University of Auckland. The funders played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; nor the decision to submit the manuscript for publication. We acknowledge all the members of the Growing Up in New Zealand team, including those members and managers of the operational (in-person and computer-assisted telephone interviewing), data, communications, community, and quality aspects of the study. We acknowledge the ongoing support and advice provided by our Kaitiaki Group and our national and international Expert Scientific Advisory Group. We also acknowledge the members of the Morton Consortium responsible for planning and design of this study in the Development Phase. We thank Sarah-Jane Paine (The University of Auckland) for data analysis guidance.

Correspondence

Professor Cameron Grant: Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Wellesley Street, Auckland 1142, New Zealand. +64 9 923 6192.

Correspondence Email

cc.grant@auckland.ac.nz

Competing Interests

Nil.

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35) Hackman NM, Schaefer EW, Beiler JS, et al. Breastfeeding outcome comparison by parity. Breastfeed Med. 2015; 10:156-62.

36) World Health Organization. WHO EURO Working Group on Vaccine Communications. 2011.

37) Petousis-Harris H, Turner N, Kerse N. New Zealand mothers’ knowledge of and attitudes towards immunisation. NZ Fam Physicia. 2002; 29:240-6.

38) Lee CHJ, Duck IM, Sibley CG. Personality and demographic correlates of New Zealanders' confidence in the safety of childhood vaccinations. Vaccine. 2017; 35:6089-95.

39) Browne M, Thomson P, Rockloff MJ, et al. Going against the Herd: Psychological and Cultural Factors Underlying the 'Vaccination Confidence Gap'. PLoS ONE. 2015; 10:e0132562.

40) Cattaneo A. Academy of breastfeeding medicine founder's lecture 2011: inequalities and inequities in breastfeeding: an international perspective. Breastfeed Med. 2012; 7:3-9.

41) Department of Prime Minister and Cabinet. Future of Health | Te Anamata o Te Oranga. Edition. Wellington, NZ: Department of Prime Minister and Cabinet, cited 13 December 2021 2021]. Available from: https://www.futureofhealth.govt.nz/

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Māori mothers have the right to breastfeed their infants. This is recognised in the United Nations (UN) Convention on the Rights of the Child,[[1]] and the right to traditional practices in the UN Declaration on the Rights of Indigenous Peoples[[2]] and the Treaty of Waitangi.[[3]] For Māori, tamariki (children) are taonga (treasured), and breastfeeding is tika tūāpapa (a fundamental right). Within Te Ao Māori (Māori worldview), breastfeeding is a fundamental aspect of tikanga Māori (Māori cultural traditions/practices) that needs to be protected and promoted.[[4]] Breastfeeding for wāhine Māori (Māori women) is a tikanga informed by mātauranga Māori (Māori knowledge) accumulated from generations of whakapapa (Māori genealogy).

Exclusive breastfeeding is beneficial short-term and long-term to both infant and mother.[[5]] Exclusive breastfeeding for six versus four months protects against gastroenteritis and promotes maternal amenorrhea and weight loss.[[6]] Breastfeeding also has economic and environmental benefits.[[7]] The New Zealand Ministry of Health[[8]] and the World Health Organization (WHO),[[9]] recommend exclusive breastfeeding for six months. The 2025 Global Nutritional Target is exclusive breastfeeding for 50% of children under six-months-old.[[10]] Despite this, exclusive breastfeeding rates in high-income countries remain low.[[5]] In Aotearoa New Zealand, while breastfeeding initiation is almost universal (97%), only 16% of children are exclusively breastfed to age six months.[[11]]

Determinants of breastfeeding initiation relate to immediate medical and social supports.[[12]] However, this is not the case for exclusive breastfeeding duration, with various economic, political, historic and cultural factors; social and health professional supports; and individual biopsychosocial factors involved.[[5,12]] Different factors affect different peoples and hence there are strong recommendations for country- and culture-specific research to inform practice and policy.[[6]]

One New Zealand qualitative study identified five ways to improve exclusive breastfeeding for Māori: (i) smoking cessation during pregnancy; (ii) breastfeeding guidelines aligned with Māori beliefs; (iii) guidelines emphasising breastfeeding benefits to mother and child; (iv) education on fertility, bed-sharing and tobacco in regard to breastfeeding; and (v) healthcare provider recognition of the social and cultural circumstances for Māori mothers and whānau (family).[[4]] In another study with predominantly Māori participants, increased breastfeeding duration was associated with partner and whānau support at one month post-partum, intention to breastfeed and being an older mother.[[13]] Decreased breastfeeding duration was associated with pacifier use, cigarette smoking, alcohol use, and household deprivation.[[13]]

To address the limited contemporary data on exclusive breastfeeding for Māori women, this study aimed to identify independent determinants of exclusive breastfeeding for six-or-more months for Māori women enrolled in Growing Up in New Zealand (GUiNZ).[[14]] In this study, analyses followed a contemporary Māori model of health and wellbeing developed by Māori researchers specifically for the GUiNZ Māori cohort. This research will inform future interventions to protect, promote and support Māori in exclusive breastfeeding.

Methods

Study design and setting

We completed this study within New Zealand’s contemporary child cohort study, Growing Up in New Zealand (GUiNZ, www.growingup.co.nz). GUiNZ study design and cohort profile are described elsewhere.[[14]] Approximately 30% of the Māori population of New Zealand reside in the study region, with 9% of Māori women who gave birth in New Zealand during the recruitment period enrolled.[[15]] The New Zealand Ministry of Health Regional Ethics Committee granted ethical approval and all study participants provided written informed consent.

Study population and sample

GUiNZ recruited 6,822 pregnant women and their 6,853 children.[[14]] At enrolment, women identified all ethnic groups to which they belonged. This study limited the sample to the 1,060/6,822 (16%) pregnant women who self-identified Māori as one of their stated ethnicities, had singleton births and provided information on exclusive breastfeeding duration at nine-month interview.

View Figure 1.

Data collection

GUiNZ collected information in six interconnected domains: health and wellbeing; psychosocial and cognitive development; education; family and whānau; culture and identity; and social context, neighbourhood and environment, with a Māori theme running across all domains.[[14]] The Māori theme and kaitiaki (guardianship) advisory group allow for the examination of factors contributing to the wellbeing of tamariki Māori and their whānau over time.[[14]]

Data were collected antenatally; perinatally; when the infant was six weeks old and nine months old. Mothers were interviewed face-to-face or via telephone as described.[[14]] Linkage to birth records occurred via each child’s National Health Index (NHI) number, a unique identifier assigned to each person in New Zealand at their first contact with the New Zealand healthcare system.

Exclusive breastfeeding duration

The WHO define exclusive breastfeeding as receiving only breastmilk (including expressed milk) and not any water, milk formula, other liquids, or solid food; but with medicines, vitamins and minerals allowed.[[10]] Maternal recall overestimates exclusive breastfeeding duration. Therefore, we used maternal recall adjusted for age of first food introduction to describe exclusive breastfeeding duration.[[11]]

Te Anga o ngā Horopaki Māori: a conceptual framework for considering Māori lived realities

This study framed analyses within a conceptual model of health and wellbeing for contemporary Māori lived realities (circumstances and environments), developed specifically for Māori participants of GUiNZ. Te Anga o ngā Horopaki Māori draws on Sir Mason Durie’s Te Whare Tapa Whā,[[16]] and other Māori models of health and wellbeing (Meihana,[[17]] Te Wheke[[18]] and Ngā Pou Mana[[19]]) to inform its design and represent contemporary Māori perspectives of health and wellbeing. Te Whare Tapa Whā conceptualises health holistically as the four sides of a whare (house): taha wairua (spiritual), taha hinengaro (thoughts and feelings), taha tinana (physical) and taha whānau (family and community relationships).[[16]] In collaboration with Te Puni Kōkiri, the framework was aligned with current Māori policies and health strategies.[[20]] Te Anga o ngā Horopaki Māori comprises six interconnected domains: Mahi Arataki (Policy and strategy); Te Ao Māori (Cultural identity); Whai rawa (Economic resources and capability); Taiao a hapori (Environment and community); Whanaungatanga (Family and home); and Hauora (Health and wellbeing) (Figure 2; see Appendix 1 for a description domains and associated assessment tools and measures). Te Anga o ngā Horopaki Māori allowed us to consider a range of factors related to exclusive breastfeeding within a context aligned with Māori perspectives of health and wellbeing.

View Figure 2.

Study power and sample size

GUiNZ recruited 6,822 pregnant women and their 6,853 children.[[14]] This study size provided adequate statistical power to undertake complex analyses of interwoven developmental trajectories over time, in the whole cohort and within subgroups of children identifying as Māori, Pacific and Asian ethnicity.[[14]] Study power calculations for GUiNZ were based upon the study being specifically designed to have adequate explanatory power for the main ethnic groups in New Zealand, with the assumption then that study power for the whole cohort would be adequate. For example, a sample size of 1,000, which was exceeded by each of the four main New Zealand ethnic groups at enrolment (NZ European n=4,237; Māori n=1,246; Pacific n=1,151; Asian n=1,074)[[21]] has 80% power at the 0.05 level of significance to detect a relative risk of 2.1 for an outcome which is found in 10% of the unexposed population if 10% of the population is exposed, and 80% power at the 0.05 level of significance to detect a difference of approximately 0.4 standard deviations between the exposed and unexposed group, if 5% of the population is exposed.[[22]] In this study, of the 1,060 wāhine Māori who had singleton births and provided information on exclusive breastfeeding duration at nine-month interview, we had sufficient power to investigate exposures affecting at least 10% of the cohort with an associated increased odds in outcome that is generally considered both statistically and clinically significant.

Data analyses

Te Anga o ngā Horopaki Māori and literature review identified variables potentially associated with exclusive breastfeeding duration. Associations with exclusive breastfeeding duration were determined using the Chi-square test for proportions, and the t-test or Wilcoxon Rank-Sum test for normally and non-normally distributed continuous variables, respectively.

Variables were included in the multivariate model when P<0.20, or if they were significant in published studies, or were important in describing each domain within Te Anga o nga Horopaki Māori. We constructed the multivariate model hierarchically: beginning with the domain most distal to the mother and infant (Mahi Arataki) and adding individual variables stepwise towards the most proximal (Hauora) domain (Figure 1). Variables were retained for subsequent analysis steps if P<0.20. If no variables in a domain had P<0.20 then the variable within each domain with the lowest P value was retained for the remainder of the analyses. Independent associations with exclusive breastfeeding duration of six-or-more months were determined using multivariable logistic regression, and described using adjusted odds ratios (aOR) and 95% confidence intervals (CI). SAS 9.4 (Cary, NC, USA) was used for all analyses.

Results

Study population and sample

Wāhine Māori comprised 1,260/6,822 (18%) of the GUiNZ cohort (Figure 1). This study was limited to the 1060/6822 (16%) wāhine Māori who had singleton births and provided information about breastfeeding when their infant was nine months old.

Breastfeeding in wāhine Māori

Overall, 6,083/6,274 (97%) pregnant women reported breastfeeding their child. Almost all wāhine Māori initiated breastfeeding (1,068/1,117; 96%), as did non-Māori women (5,014/5,156; 97%) although these differences were statistically significant (P=0.004) (Table 1). However, 132/1,060 (12%) wāhine Māori and 868/4,972 (17%) non-Māori breastfeed for six-or-more months (P<0.001) (Table 1). Median (interquartile range [IQR]) exclusive breastfeeding duration was 3 (2–4) months for wāhine Māori and 4 (2–5) months for non-Māori (P<0.001).

View Table 1.

Identification of variables for hierarchical logistic regression modelling

Preliminary analyses within Te Anga o ngā Horopaki Māori revealed 32 variables potentially associated with exclusive breastfeeding in wāhine Māori. Each variable was situated within one of the six interconnected Te Anga o ngā Horopaki Māori domains: Mahi Arataki (Appendix 2); Te Ao Māori (Appendix 3); Whai Rawa (Appendix 4); Taiao a Hapori (Appendix 5); Whanaungatanga (Appendix 6); and Hauora (Appendix 7).

Characteristics associated with exclusive breastfeeding in wāhine Māori

Hierarchal logistic regression analyses consisted of sequential steps within Te Anga o ngā Horopaki Māori as described (Methods; Supplementary Figure 1). The final model included 17 variables, with at least one variable from each Te Anga o ngā Horopaki Māori domain (Table 2). Based on these analyses, six variables in four Te Anga o ngā Horopaki Māori domains were independently associated with exclusive breastfeeding for six-or-more months.

Within Mahi Arataki, wāhine Māori were more likely to exclusively breastfeed for six-or-more months, if they had thought, antenatally, that it was best to breastfeed for longer than six months (aOR=1.94, 95% CI 1.05–3.78) versus up to six months. Wāhine Māori who thought their breastfeeding duration would not be limited (aOR=2.17, 95% CI 1.17–4.24) or may be limited (aOR=4.25, 95% CI 1.86–9.85) by their return to work were more likely to exclusively breastfeed for six-or-more months, compared with mothers who thought their breastfeeding duration would be limited by their return to work.

Within Te Ao Māori, wāhine Māori who rated maintaining cultural traditions and practices as “fairly important” (aOR=0.53, 95% CI 0.27–0.99) were less likely to exclusively breastfeed their infant for six-or-more months, compared with women who rated these as “very important”.

Within whanaungatanga, experienced Māori mothers (aOR=2.55, 95% CI 1.35–5.06), compared to first-time mothers, were more likely to exclusively breastfeed for six-or-more months.

Within Hauora, mothers who experienced depression during pregnancy (aOR=0.47, 95% CI 0.20–0.99) were less likely to exclusively breastfeed their infant for six-or-more months than those without depression symptoms. Mothers who remained undecided about their child’s infant immunisations (aOR=3.16, 95% CI 1.55–6.39) were more likely to exclusively breastfeed for six ormore months than mothers who had decided about immunisation.

View Table 2.

Discussion

In this contemporary cohort of New Zealand mothers, breastfeeding initiation was almost universal with 96% of wāhine Māori and 97% of non-Māori women initiating breastfeeding. Yet exclusive breastfeeding rates remain poor, with 17% of non-Māori and 12% of wāhine Māori exclusively breastfeeding their infants for the recommended six months. Therefore, significant improvement in exclusive breastfeeding rates is needed for New Zealand to achieve the Global Nutrition Target for 2025 of 50% of infants under six months old exclusively breastfeeding.[[10]]

The New Zealand Ministry of Health and WHO recommend exclusive breastfeeding for six months followed by continued breastfeeding with complementary foods up to two years old.[[8,10]] When Māori mothers’ breastfeeding beliefs aligned with these recommendations, they were more likely to exclusively breastfeed for six-or-more months. Mothers often decide about breastfeeding prior to or early in pregnancy,[[24]] and access to high quality breastfeeding information can inform their decision-making.[[25]] Māori mothers and grandmothers also highlight breastfeeding role models, whānau support, culturally safe healthcare, and wider community acceptance of breastfeeding, all as important for supporting breastfeeding.[[25]] Whānau are central to breastfeeding decision-making and support.[[26]] Public health policies that encourage delivery of high quality breastfeeding information to wāhine Māori and whānau in a culturally safe, accessible and effective way are important for promoting and supporting breastfeeding and whānau ora (family health and development).

Analyses within Te Anga o ngā Horopaki Māori model of health revealed six determinants of exclusive breastfeeding for Māori mothers within four model domains. Although the Whai Rawa and Taiao a Hapori domains were unrepresented, the overlapping nature of domains within Te Anga o ngā Horopaki Māori means that variables from other domains (i.e., return to work and maintaining cultural traditions/practices) intersect with these domains.

Mothers’ return to work is well recognised as a determinant of exclusive breastfeeding duration,[[27]] and was identified as a major theme in qualitative analyses of breastfeeding barriers in wāhine Māori.[[28]] Paid parental leave in New Zealand increased from 13 weeks during the study period to 26 weeks in 2019.[[29]] The eligibility criteria have also broadened to include more casual workers. It is important to assess if this policy change has had a positive influence on Māori exclusive breastfeeding rates, and whether current policy supports Māori to access paid parental leave.

Wāhine Māori consider breastfeeding the natural, normal and Māori way to feed their pēpē (baby)[[30]] and a fundamental aspect of tikanga Māori.[[4]] Wāhine Māori in our study who rated maintaining cultural traditions and practices as “fairly important”, compared with very important, were slightly less likely to exclusively breastfeed their infant for six-or-more months, although this finding was not statistically significant. The legacy of colonisation, poverty, and systemic racism limits access to Te Ao Māori to a privileged few. Pākehā (European) colonisation of New Zealand profoundly impacted breastfeeding for Māori.[[30]] In pre-colonial times, Māori infants were breastfed by their mothers or other lactating women.[[31]] Western reframing of Indigenous knowledge and beliefs as myths and legends,[[3]] the Tohunga (traditional healer) Suppression Act (1907–1962) and the general, but erroneous, belief that there was a law preventing wāhine Māori from breastfeeding in public[[28]] combined to reduce Māori breastfeeding rates. Throughout the 20th century, the medicalisation of birth and the introduction of infant formula undermined the rich breastfeeding knowledge shared between women, particularly wāhine Māori, leading to a significant decline in breastfeeding rates.[[32]] Contemporary Māori mothers report professional insensitivity and conflicting advice about breastfeeding as contributing to lack of confidence in healthcare providers.[[30]]

Mothers who experience depression during pregnancy are less likely to initiate breastfeeding, and more likely to cease exclusive breastfeeding before six months.[[33]] We found that Māori mothers who experienced depression during pregnancy were less likely to exclusively breastfeed for six-or-more months. There is also evidence that early cessation of breastfeeding is a risk factor for maternal anxiety and depression.[[34]] Together, these findings highlight the importance of routine perinatal depression screening, and of providing culturally safe breastfeeding and mental health support to Māori mothers exhibiting depression symptoms.

Previous studies have identified smoking as a barrier to exclusive breastfeeding for Māori mothers.[[4,13]] One-third of mothers in our study reported smoking during pregnancy; however, the association between smoking and exclusive breastfeeding was excluded from our final model. When included in the model, there was no significant association between smoking and exclusive breastfeeding (results not shown).

We found that Māori mothers with more than one child were more likely to exclusively breastfeed for six-or-more months than first time mothers, similar to findings for the whole GUiNZ cohort and other studies.[[11,35]] Thus, first time Māori mothers may benefit from additional breastfeeding support from whānau, community and healthcare providers.

According to WHO, vaccine hesitancy is one of the top ten threats to global health. Hesitancy is due to a combination of a lack of confidence in the vaccine or healthcare provider; complacency towards the disease or the vaccine; and convenience or vaccine access.[[36]] Historically, there are multiple reasons for wāhine Māori to distrust infant nutrition recommendations from New Zealand healthcare providers. The message that breastfeeding strengthens the immune system may contribute to complacency with respect to immunisation.[[37]] Wāhine Māori report breastfeeding as tikanga Māori,[[30]] whereas immunisations are not reported in the same light.[[38]] Finances, time, geography, and cultural access, whereby vaccines are not promoted in line with tikanga Māori, are all important barriers to immunisation.[[39]] Addressing present and historic distrust of the health system and creating an environment where immunisation supports Māori perspectives of health and wellbeing may improve both breastfeeding and immunisation rates.

Antenatal recruitment with adequate explanatory power for analyses within the Māori cohort is a strength of our study.[[14]] Breastfeeding and food introduction were one of a number of domains about which study participants were questioned, therefore reducing the likelihood of reporting bias. A limitation of our study was maternal recall bias of exclusive breastfeeding; however, we minimised this by adjusting for the age of food introduction.[[11]] This study supports the use of Māori models of health in the quantitative analysis of exclusive breastfeeding, but acknowledges the limitations with exclusion of whānau responses.

Breastfeeding interventions aim to protect, promote, and support breastfeeding.[[40]] Protection is the most effective intervention in reducing inequities, occurs at a population level and involves legislation, regulations and policy. Policy directed at protecting breastfeeding in the workplace and public spaces must acknowledge historical wrongs Māori have faced, and must be centred on breastfeeding as tikanga Māori. To reduce inequities, legislation must include adequate enforcement of these policies, rather than relying on guidelines, and monitoring of breastfeeding must be representative of Māori. Recent improvements to parental leave provisions go some way to reducing inequities;[[29]] however not all mothers are eligible. Universal paid parental leave would provide breastfeeding protection.

Breastfeeding promotion should commence prior to or early in pregnancy and include mothers, whānau, health professionals and society as a whole.[[40]] Policy changes that provide kaupapa Māori pregnancy, childbirth and infant healthcare; increase Māori participation in midwifery and well-child care; and include whānau in healthcare decision-making are essential to improving outcomes for wāhine Māori and their pēpē.

Improving Māori health outcomes and honouring the principles of Te Tiriti o Waitangi are central components of current New Zealand health system reform.[[41]] The establishment of national entities, Te Mana Hauora Māori (Māori Health Authority) and Hauora Aotearoa (Health New Zealand), will change the way the health system understands and responds to Māori health needs, drive the provision of kaupapa Māori services and develop policy and strategy to improve health outcomes for Māori. Iwi–Māori Partnership Boards will be the primary source of whānau voice, will have decision-making roles at the local level, and will work with the national entities to determine local priorities and healthcare delivery. A whole of system approach to healthcare reform must address structural racism and empower tangata whenua and tauiwi (non-Māori) to fully engage in promoting health equity for Māori.

Conclusion

While most Māori mothers initiate breastfeeding, only a small proportion continue exclusive breastfeeding until their infant is aged six months. Determinants of exclusive breastfeeding in wāhine Māori are knowledge of breastfeeding recommendations, return to work, motherhood experience, connection to Māori cultural traditions/practices, antenatal depression, and vaccine indecision. Proposed New Zealand health system reforms aim to honour Te Tiriti o Waitangi principles and address the legacy of colonisation, poverty, and systemic racism on Hauora Māori. These reforms should allow the development of breastfeeding policy and interventions that acknowledge and redress the damage that breastfeeding policies have historically had on Māori. Interventions delivered within a kaupapa Māori framework will best address breastfeeding inequities in New Zealand. Health equity for Māori has the potential to improve health outcomes for all New Zealanders.

View Appendices.

Summary

The findings of this research can be used to inform future interventions to protect, promote and support Māori in exclusive breastfeeding. Aotearoa New Zealand is not meeting global nutrition targets for exclusive breastfeeding of infants until six months. While nearly all non-Māori women and wāhine Māori start breastfeeding, only 17% of non-Māori and 12% of wāhine Māori continue to exclusively breastfeed for the recommended six months. Breastfeeding is a fundamental aspect of tikanga Māori (Māori cultural traditions/practices) requiring protection and promotion. Interventions delivered within a kaupapa Māori framework will best address breastfeeding inequities in Aotearoa New Zealand. Mothers who felt that returning to work would limit breastfeeding were less likely to carry on exclusively until six months. Paid parental leave is currently six months, but this will only cover up to about five and half months of baby’s life, and not all women have access to paid leave.

Abstract

Aim

Breastfeeding is a fundamental aspect of tikanga Māori(Māori cultural traditions/practices) requiring protection and promotion. This studyidentifies determinants of exclusive breastfeeding in wāhine Māori (Māori women).

Method

Wāhine Māori enrolled in the Growing Up in New Zealand child cohort study participated (n=1060). Exclusive breastfeeding duration was self-reported. Hierarchical regression analyses were framed by a model of Māori health and wellbeing.

Results

Most wāhine Māori initiated breastfeeding (96%), with 12% exclusively breastfeeding for six- or-more months. Wāhine Māori had increased odds of exclusively breastfeeding for six-or-more months if they: thought it best to breastfeed for >6 months (adjusted odds ratio (aOR)=1.94, 95% confidence interval (CI)=1.05-3.78); thought returning to work would not (aOR=2.17, 95% CI=1.17–4.24) or may (aOR=4.25, 95% CI=1.86–9.85) limit breastfeeding; were experienced mothers (aOR=2.55, 95% CI=1.35–5.06); or were undecided about vaccination (aOR=3.16, 95% CI=1.55–6.39). Exclusive breastfeeding for six-or-more months was less likely if mothers experienced depression during pregnancy (aOR=0.47, 95% CI=0.20–0.99) or viewed cultural traditions/practices as “fairly important” (aOR=0.53, 95% CI=0.27–0.99), compared to “very important”.

Conclusion

Determinants of exclusive breastfeeding in wāhine Māori are knowledge of breastfeeding recommendations, return to work, motherhood experience, connection to Te Ao Māori (Māori worldview) and tikanga Māori, antenatal depression and vaccine indecision. Interventions delivered within a Kaupapa Māori framework will best address breastfeeding inequities in Aotearoa New Zealand.

Author Information

Denise Bennett: Paediatrician, General Paediatrics, Kidz First Hospital, Counties Manukau District Health Board, Auckland. Catherine A Gilchrist: Lecturer, Department of Paediatrics: Child & Youth health, The University of Auckland, Auckland. Rochelle L Menzies: Research Fellow, Koi Tū: The Centre for Informed Futures, The University of Auckland, Auckland. Matire Harwood: Associate Professor, Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland, Auckland. Te Kani Kingi: Professor, Te Mata o te Tau, Ngā Pae o te Māramatanga – The Academy for Māori Research and Scholarship, Massey University. Polly Atatoa Carr: Associate Professor, National Institute of Demographic and Economic Analysis, Faculty of Arts and Social Sciences, The University of Waikato, Hamilton; Growing Up in New Zealand, The University of Auckland, Auckland; Centre for Longitudinal Research – He Ara ki Mua, The University of Auckland, Auckland. Susan Morton: Professor and Director, Centre for Longitudinal Research – He Ara ki Mua, The University of Auckland, Auckland; Growing Up in New Zealand, The University of Auckland, Auckland. Cameron C Grant: Professor of Paediatrics, Department of Paediatrics: Child & Youth health, The University of Auckland, Auckland; Growing Up in New Zealand, The University of Auckland, Auckland; Centre for Longitudinal Research – He Ara ki Mua, The University of Auckland, Auckland; General Paediatrics, Starship Children’s Hospital, Auckland District Health Board, Auckland.

Acknowledgements

Most importantly, we would like to acknowledge the children and the families who are part of the Growing Up in New Zealand study. We would also like to acknowledge the initial funders, in particular the New Zealand Ministry of Social Development, supported by the Health Research Council, as well as the ongoing support from Auckland UniServices and The University of Auckland. The funders played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; nor the decision to submit the manuscript for publication. We acknowledge all the members of the Growing Up in New Zealand team, including those members and managers of the operational (in-person and computer-assisted telephone interviewing), data, communications, community, and quality aspects of the study. We acknowledge the ongoing support and advice provided by our Kaitiaki Group and our national and international Expert Scientific Advisory Group. We also acknowledge the members of the Morton Consortium responsible for planning and design of this study in the Development Phase. We thank Sarah-Jane Paine (The University of Auckland) for data analysis guidance.

Correspondence

Professor Cameron Grant: Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Wellesley Street, Auckland 1142, New Zealand. +64 9 923 6192.

Correspondence Email

cc.grant@auckland.ac.nz

Competing Interests

Nil.

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26) Glover M, Manaena-Biddle H, Waldon J. The Role of Whānau in Māori Women's Decisions about Breast Feeding. AlterNative: An International Journal of Indigenous Peoples. 2006; 3:140-57.

27) Ogbuanu C, Glover S, Probst J, et al. The effect of maternity leave length and time of return to work on breastfeeding. Pediatrics. 2011; 127:e1414-27.

28) Glover M, Manaena-Biddle H, Waldon J. Influences that affect Maori women breastfeeding. Breastfeed Rev. 2007; 15:5-14.

29) New Zealand Government. Taking parental leave. Edition. Wellington, New Zealand: New Zealand Government, cited 20 June 2019 2019]. Available from: https://www.govt.nz/browse/work/parental-leave/taking-parental-leave/

30) Gosman HG. What Influences Infant Feeding Decisions for Māori Mothers Aged 15-24 years? Nursing and Health Science. Napier, New Zealand: Eastern Institute of Technology, 2015.

31) Clarke A. Born to a changing world: Childbirth in nineteenth-century New Zealand. . Wellington, New Zealand: Bridget Williams Books, 2012.

32) McBride-Henry K, Clendon J. Breastfeeding in New Zealand from colonisation until the year 1980: An historical review. New Zealand College of Midwives Journal. 2010; 43:10-20.

33) Amiel Castro RT, Glover V, Ehlert U, et al. Antenatal psychological and socioeconomic predictors of breastfeeding in a large community sample. Early Hum Dev. 2017; 110:50-6.

34) Ystrom E. Breastfeeding cessation and symptoms of anxiety and depression: a longitudinal cohort study. BMC Pregnancy Childbirth. 2012; 12:36.

35) Hackman NM, Schaefer EW, Beiler JS, et al. Breastfeeding outcome comparison by parity. Breastfeed Med. 2015; 10:156-62.

36) World Health Organization. WHO EURO Working Group on Vaccine Communications. 2011.

37) Petousis-Harris H, Turner N, Kerse N. New Zealand mothers’ knowledge of and attitudes towards immunisation. NZ Fam Physicia. 2002; 29:240-6.

38) Lee CHJ, Duck IM, Sibley CG. Personality and demographic correlates of New Zealanders' confidence in the safety of childhood vaccinations. Vaccine. 2017; 35:6089-95.

39) Browne M, Thomson P, Rockloff MJ, et al. Going against the Herd: Psychological and Cultural Factors Underlying the 'Vaccination Confidence Gap'. PLoS ONE. 2015; 10:e0132562.

40) Cattaneo A. Academy of breastfeeding medicine founder's lecture 2011: inequalities and inequities in breastfeeding: an international perspective. Breastfeed Med. 2012; 7:3-9.

41) Department of Prime Minister and Cabinet. Future of Health | Te Anamata o Te Oranga. Edition. Wellington, NZ: Department of Prime Minister and Cabinet, cited 13 December 2021 2021]. Available from: https://www.futureofhealth.govt.nz/

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Māori mothers have the right to breastfeed their infants. This is recognised in the United Nations (UN) Convention on the Rights of the Child,[[1]] and the right to traditional practices in the UN Declaration on the Rights of Indigenous Peoples[[2]] and the Treaty of Waitangi.[[3]] For Māori, tamariki (children) are taonga (treasured), and breastfeeding is tika tūāpapa (a fundamental right). Within Te Ao Māori (Māori worldview), breastfeeding is a fundamental aspect of tikanga Māori (Māori cultural traditions/practices) that needs to be protected and promoted.[[4]] Breastfeeding for wāhine Māori (Māori women) is a tikanga informed by mātauranga Māori (Māori knowledge) accumulated from generations of whakapapa (Māori genealogy).

Exclusive breastfeeding is beneficial short-term and long-term to both infant and mother.[[5]] Exclusive breastfeeding for six versus four months protects against gastroenteritis and promotes maternal amenorrhea and weight loss.[[6]] Breastfeeding also has economic and environmental benefits.[[7]] The New Zealand Ministry of Health[[8]] and the World Health Organization (WHO),[[9]] recommend exclusive breastfeeding for six months. The 2025 Global Nutritional Target is exclusive breastfeeding for 50% of children under six-months-old.[[10]] Despite this, exclusive breastfeeding rates in high-income countries remain low.[[5]] In Aotearoa New Zealand, while breastfeeding initiation is almost universal (97%), only 16% of children are exclusively breastfed to age six months.[[11]]

Determinants of breastfeeding initiation relate to immediate medical and social supports.[[12]] However, this is not the case for exclusive breastfeeding duration, with various economic, political, historic and cultural factors; social and health professional supports; and individual biopsychosocial factors involved.[[5,12]] Different factors affect different peoples and hence there are strong recommendations for country- and culture-specific research to inform practice and policy.[[6]]

One New Zealand qualitative study identified five ways to improve exclusive breastfeeding for Māori: (i) smoking cessation during pregnancy; (ii) breastfeeding guidelines aligned with Māori beliefs; (iii) guidelines emphasising breastfeeding benefits to mother and child; (iv) education on fertility, bed-sharing and tobacco in regard to breastfeeding; and (v) healthcare provider recognition of the social and cultural circumstances for Māori mothers and whānau (family).[[4]] In another study with predominantly Māori participants, increased breastfeeding duration was associated with partner and whānau support at one month post-partum, intention to breastfeed and being an older mother.[[13]] Decreased breastfeeding duration was associated with pacifier use, cigarette smoking, alcohol use, and household deprivation.[[13]]

To address the limited contemporary data on exclusive breastfeeding for Māori women, this study aimed to identify independent determinants of exclusive breastfeeding for six-or-more months for Māori women enrolled in Growing Up in New Zealand (GUiNZ).[[14]] In this study, analyses followed a contemporary Māori model of health and wellbeing developed by Māori researchers specifically for the GUiNZ Māori cohort. This research will inform future interventions to protect, promote and support Māori in exclusive breastfeeding.

Methods

Study design and setting

We completed this study within New Zealand’s contemporary child cohort study, Growing Up in New Zealand (GUiNZ, www.growingup.co.nz). GUiNZ study design and cohort profile are described elsewhere.[[14]] Approximately 30% of the Māori population of New Zealand reside in the study region, with 9% of Māori women who gave birth in New Zealand during the recruitment period enrolled.[[15]] The New Zealand Ministry of Health Regional Ethics Committee granted ethical approval and all study participants provided written informed consent.

Study population and sample

GUiNZ recruited 6,822 pregnant women and their 6,853 children.[[14]] At enrolment, women identified all ethnic groups to which they belonged. This study limited the sample to the 1,060/6,822 (16%) pregnant women who self-identified Māori as one of their stated ethnicities, had singleton births and provided information on exclusive breastfeeding duration at nine-month interview.

View Figure 1.

Data collection

GUiNZ collected information in six interconnected domains: health and wellbeing; psychosocial and cognitive development; education; family and whānau; culture and identity; and social context, neighbourhood and environment, with a Māori theme running across all domains.[[14]] The Māori theme and kaitiaki (guardianship) advisory group allow for the examination of factors contributing to the wellbeing of tamariki Māori and their whānau over time.[[14]]

Data were collected antenatally; perinatally; when the infant was six weeks old and nine months old. Mothers were interviewed face-to-face or via telephone as described.[[14]] Linkage to birth records occurred via each child’s National Health Index (NHI) number, a unique identifier assigned to each person in New Zealand at their first contact with the New Zealand healthcare system.

Exclusive breastfeeding duration

The WHO define exclusive breastfeeding as receiving only breastmilk (including expressed milk) and not any water, milk formula, other liquids, or solid food; but with medicines, vitamins and minerals allowed.[[10]] Maternal recall overestimates exclusive breastfeeding duration. Therefore, we used maternal recall adjusted for age of first food introduction to describe exclusive breastfeeding duration.[[11]]

Te Anga o ngā Horopaki Māori: a conceptual framework for considering Māori lived realities

This study framed analyses within a conceptual model of health and wellbeing for contemporary Māori lived realities (circumstances and environments), developed specifically for Māori participants of GUiNZ. Te Anga o ngā Horopaki Māori draws on Sir Mason Durie’s Te Whare Tapa Whā,[[16]] and other Māori models of health and wellbeing (Meihana,[[17]] Te Wheke[[18]] and Ngā Pou Mana[[19]]) to inform its design and represent contemporary Māori perspectives of health and wellbeing. Te Whare Tapa Whā conceptualises health holistically as the four sides of a whare (house): taha wairua (spiritual), taha hinengaro (thoughts and feelings), taha tinana (physical) and taha whānau (family and community relationships).[[16]] In collaboration with Te Puni Kōkiri, the framework was aligned with current Māori policies and health strategies.[[20]] Te Anga o ngā Horopaki Māori comprises six interconnected domains: Mahi Arataki (Policy and strategy); Te Ao Māori (Cultural identity); Whai rawa (Economic resources and capability); Taiao a hapori (Environment and community); Whanaungatanga (Family and home); and Hauora (Health and wellbeing) (Figure 2; see Appendix 1 for a description domains and associated assessment tools and measures). Te Anga o ngā Horopaki Māori allowed us to consider a range of factors related to exclusive breastfeeding within a context aligned with Māori perspectives of health and wellbeing.

View Figure 2.

Study power and sample size

GUiNZ recruited 6,822 pregnant women and their 6,853 children.[[14]] This study size provided adequate statistical power to undertake complex analyses of interwoven developmental trajectories over time, in the whole cohort and within subgroups of children identifying as Māori, Pacific and Asian ethnicity.[[14]] Study power calculations for GUiNZ were based upon the study being specifically designed to have adequate explanatory power for the main ethnic groups in New Zealand, with the assumption then that study power for the whole cohort would be adequate. For example, a sample size of 1,000, which was exceeded by each of the four main New Zealand ethnic groups at enrolment (NZ European n=4,237; Māori n=1,246; Pacific n=1,151; Asian n=1,074)[[21]] has 80% power at the 0.05 level of significance to detect a relative risk of 2.1 for an outcome which is found in 10% of the unexposed population if 10% of the population is exposed, and 80% power at the 0.05 level of significance to detect a difference of approximately 0.4 standard deviations between the exposed and unexposed group, if 5% of the population is exposed.[[22]] In this study, of the 1,060 wāhine Māori who had singleton births and provided information on exclusive breastfeeding duration at nine-month interview, we had sufficient power to investigate exposures affecting at least 10% of the cohort with an associated increased odds in outcome that is generally considered both statistically and clinically significant.

Data analyses

Te Anga o ngā Horopaki Māori and literature review identified variables potentially associated with exclusive breastfeeding duration. Associations with exclusive breastfeeding duration were determined using the Chi-square test for proportions, and the t-test or Wilcoxon Rank-Sum test for normally and non-normally distributed continuous variables, respectively.

Variables were included in the multivariate model when P<0.20, or if they were significant in published studies, or were important in describing each domain within Te Anga o nga Horopaki Māori. We constructed the multivariate model hierarchically: beginning with the domain most distal to the mother and infant (Mahi Arataki) and adding individual variables stepwise towards the most proximal (Hauora) domain (Figure 1). Variables were retained for subsequent analysis steps if P<0.20. If no variables in a domain had P<0.20 then the variable within each domain with the lowest P value was retained for the remainder of the analyses. Independent associations with exclusive breastfeeding duration of six-or-more months were determined using multivariable logistic regression, and described using adjusted odds ratios (aOR) and 95% confidence intervals (CI). SAS 9.4 (Cary, NC, USA) was used for all analyses.

Results

Study population and sample

Wāhine Māori comprised 1,260/6,822 (18%) of the GUiNZ cohort (Figure 1). This study was limited to the 1060/6822 (16%) wāhine Māori who had singleton births and provided information about breastfeeding when their infant was nine months old.

Breastfeeding in wāhine Māori

Overall, 6,083/6,274 (97%) pregnant women reported breastfeeding their child. Almost all wāhine Māori initiated breastfeeding (1,068/1,117; 96%), as did non-Māori women (5,014/5,156; 97%) although these differences were statistically significant (P=0.004) (Table 1). However, 132/1,060 (12%) wāhine Māori and 868/4,972 (17%) non-Māori breastfeed for six-or-more months (P<0.001) (Table 1). Median (interquartile range [IQR]) exclusive breastfeeding duration was 3 (2–4) months for wāhine Māori and 4 (2–5) months for non-Māori (P<0.001).

View Table 1.

Identification of variables for hierarchical logistic regression modelling

Preliminary analyses within Te Anga o ngā Horopaki Māori revealed 32 variables potentially associated with exclusive breastfeeding in wāhine Māori. Each variable was situated within one of the six interconnected Te Anga o ngā Horopaki Māori domains: Mahi Arataki (Appendix 2); Te Ao Māori (Appendix 3); Whai Rawa (Appendix 4); Taiao a Hapori (Appendix 5); Whanaungatanga (Appendix 6); and Hauora (Appendix 7).

Characteristics associated with exclusive breastfeeding in wāhine Māori

Hierarchal logistic regression analyses consisted of sequential steps within Te Anga o ngā Horopaki Māori as described (Methods; Supplementary Figure 1). The final model included 17 variables, with at least one variable from each Te Anga o ngā Horopaki Māori domain (Table 2). Based on these analyses, six variables in four Te Anga o ngā Horopaki Māori domains were independently associated with exclusive breastfeeding for six-or-more months.

Within Mahi Arataki, wāhine Māori were more likely to exclusively breastfeed for six-or-more months, if they had thought, antenatally, that it was best to breastfeed for longer than six months (aOR=1.94, 95% CI 1.05–3.78) versus up to six months. Wāhine Māori who thought their breastfeeding duration would not be limited (aOR=2.17, 95% CI 1.17–4.24) or may be limited (aOR=4.25, 95% CI 1.86–9.85) by their return to work were more likely to exclusively breastfeed for six-or-more months, compared with mothers who thought their breastfeeding duration would be limited by their return to work.

Within Te Ao Māori, wāhine Māori who rated maintaining cultural traditions and practices as “fairly important” (aOR=0.53, 95% CI 0.27–0.99) were less likely to exclusively breastfeed their infant for six-or-more months, compared with women who rated these as “very important”.

Within whanaungatanga, experienced Māori mothers (aOR=2.55, 95% CI 1.35–5.06), compared to first-time mothers, were more likely to exclusively breastfeed for six-or-more months.

Within Hauora, mothers who experienced depression during pregnancy (aOR=0.47, 95% CI 0.20–0.99) were less likely to exclusively breastfeed their infant for six-or-more months than those without depression symptoms. Mothers who remained undecided about their child’s infant immunisations (aOR=3.16, 95% CI 1.55–6.39) were more likely to exclusively breastfeed for six ormore months than mothers who had decided about immunisation.

View Table 2.

Discussion

In this contemporary cohort of New Zealand mothers, breastfeeding initiation was almost universal with 96% of wāhine Māori and 97% of non-Māori women initiating breastfeeding. Yet exclusive breastfeeding rates remain poor, with 17% of non-Māori and 12% of wāhine Māori exclusively breastfeeding their infants for the recommended six months. Therefore, significant improvement in exclusive breastfeeding rates is needed for New Zealand to achieve the Global Nutrition Target for 2025 of 50% of infants under six months old exclusively breastfeeding.[[10]]

The New Zealand Ministry of Health and WHO recommend exclusive breastfeeding for six months followed by continued breastfeeding with complementary foods up to two years old.[[8,10]] When Māori mothers’ breastfeeding beliefs aligned with these recommendations, they were more likely to exclusively breastfeed for six-or-more months. Mothers often decide about breastfeeding prior to or early in pregnancy,[[24]] and access to high quality breastfeeding information can inform their decision-making.[[25]] Māori mothers and grandmothers also highlight breastfeeding role models, whānau support, culturally safe healthcare, and wider community acceptance of breastfeeding, all as important for supporting breastfeeding.[[25]] Whānau are central to breastfeeding decision-making and support.[[26]] Public health policies that encourage delivery of high quality breastfeeding information to wāhine Māori and whānau in a culturally safe, accessible and effective way are important for promoting and supporting breastfeeding and whānau ora (family health and development).

Analyses within Te Anga o ngā Horopaki Māori model of health revealed six determinants of exclusive breastfeeding for Māori mothers within four model domains. Although the Whai Rawa and Taiao a Hapori domains were unrepresented, the overlapping nature of domains within Te Anga o ngā Horopaki Māori means that variables from other domains (i.e., return to work and maintaining cultural traditions/practices) intersect with these domains.

Mothers’ return to work is well recognised as a determinant of exclusive breastfeeding duration,[[27]] and was identified as a major theme in qualitative analyses of breastfeeding barriers in wāhine Māori.[[28]] Paid parental leave in New Zealand increased from 13 weeks during the study period to 26 weeks in 2019.[[29]] The eligibility criteria have also broadened to include more casual workers. It is important to assess if this policy change has had a positive influence on Māori exclusive breastfeeding rates, and whether current policy supports Māori to access paid parental leave.

Wāhine Māori consider breastfeeding the natural, normal and Māori way to feed their pēpē (baby)[[30]] and a fundamental aspect of tikanga Māori.[[4]] Wāhine Māori in our study who rated maintaining cultural traditions and practices as “fairly important”, compared with very important, were slightly less likely to exclusively breastfeed their infant for six-or-more months, although this finding was not statistically significant. The legacy of colonisation, poverty, and systemic racism limits access to Te Ao Māori to a privileged few. Pākehā (European) colonisation of New Zealand profoundly impacted breastfeeding for Māori.[[30]] In pre-colonial times, Māori infants were breastfed by their mothers or other lactating women.[[31]] Western reframing of Indigenous knowledge and beliefs as myths and legends,[[3]] the Tohunga (traditional healer) Suppression Act (1907–1962) and the general, but erroneous, belief that there was a law preventing wāhine Māori from breastfeeding in public[[28]] combined to reduce Māori breastfeeding rates. Throughout the 20th century, the medicalisation of birth and the introduction of infant formula undermined the rich breastfeeding knowledge shared between women, particularly wāhine Māori, leading to a significant decline in breastfeeding rates.[[32]] Contemporary Māori mothers report professional insensitivity and conflicting advice about breastfeeding as contributing to lack of confidence in healthcare providers.[[30]]

Mothers who experience depression during pregnancy are less likely to initiate breastfeeding, and more likely to cease exclusive breastfeeding before six months.[[33]] We found that Māori mothers who experienced depression during pregnancy were less likely to exclusively breastfeed for six-or-more months. There is also evidence that early cessation of breastfeeding is a risk factor for maternal anxiety and depression.[[34]] Together, these findings highlight the importance of routine perinatal depression screening, and of providing culturally safe breastfeeding and mental health support to Māori mothers exhibiting depression symptoms.

Previous studies have identified smoking as a barrier to exclusive breastfeeding for Māori mothers.[[4,13]] One-third of mothers in our study reported smoking during pregnancy; however, the association between smoking and exclusive breastfeeding was excluded from our final model. When included in the model, there was no significant association between smoking and exclusive breastfeeding (results not shown).

We found that Māori mothers with more than one child were more likely to exclusively breastfeed for six-or-more months than first time mothers, similar to findings for the whole GUiNZ cohort and other studies.[[11,35]] Thus, first time Māori mothers may benefit from additional breastfeeding support from whānau, community and healthcare providers.

According to WHO, vaccine hesitancy is one of the top ten threats to global health. Hesitancy is due to a combination of a lack of confidence in the vaccine or healthcare provider; complacency towards the disease or the vaccine; and convenience or vaccine access.[[36]] Historically, there are multiple reasons for wāhine Māori to distrust infant nutrition recommendations from New Zealand healthcare providers. The message that breastfeeding strengthens the immune system may contribute to complacency with respect to immunisation.[[37]] Wāhine Māori report breastfeeding as tikanga Māori,[[30]] whereas immunisations are not reported in the same light.[[38]] Finances, time, geography, and cultural access, whereby vaccines are not promoted in line with tikanga Māori, are all important barriers to immunisation.[[39]] Addressing present and historic distrust of the health system and creating an environment where immunisation supports Māori perspectives of health and wellbeing may improve both breastfeeding and immunisation rates.

Antenatal recruitment with adequate explanatory power for analyses within the Māori cohort is a strength of our study.[[14]] Breastfeeding and food introduction were one of a number of domains about which study participants were questioned, therefore reducing the likelihood of reporting bias. A limitation of our study was maternal recall bias of exclusive breastfeeding; however, we minimised this by adjusting for the age of food introduction.[[11]] This study supports the use of Māori models of health in the quantitative analysis of exclusive breastfeeding, but acknowledges the limitations with exclusion of whānau responses.

Breastfeeding interventions aim to protect, promote, and support breastfeeding.[[40]] Protection is the most effective intervention in reducing inequities, occurs at a population level and involves legislation, regulations and policy. Policy directed at protecting breastfeeding in the workplace and public spaces must acknowledge historical wrongs Māori have faced, and must be centred on breastfeeding as tikanga Māori. To reduce inequities, legislation must include adequate enforcement of these policies, rather than relying on guidelines, and monitoring of breastfeeding must be representative of Māori. Recent improvements to parental leave provisions go some way to reducing inequities;[[29]] however not all mothers are eligible. Universal paid parental leave would provide breastfeeding protection.

Breastfeeding promotion should commence prior to or early in pregnancy and include mothers, whānau, health professionals and society as a whole.[[40]] Policy changes that provide kaupapa Māori pregnancy, childbirth and infant healthcare; increase Māori participation in midwifery and well-child care; and include whānau in healthcare decision-making are essential to improving outcomes for wāhine Māori and their pēpē.

Improving Māori health outcomes and honouring the principles of Te Tiriti o Waitangi are central components of current New Zealand health system reform.[[41]] The establishment of national entities, Te Mana Hauora Māori (Māori Health Authority) and Hauora Aotearoa (Health New Zealand), will change the way the health system understands and responds to Māori health needs, drive the provision of kaupapa Māori services and develop policy and strategy to improve health outcomes for Māori. Iwi–Māori Partnership Boards will be the primary source of whānau voice, will have decision-making roles at the local level, and will work with the national entities to determine local priorities and healthcare delivery. A whole of system approach to healthcare reform must address structural racism and empower tangata whenua and tauiwi (non-Māori) to fully engage in promoting health equity for Māori.

Conclusion

While most Māori mothers initiate breastfeeding, only a small proportion continue exclusive breastfeeding until their infant is aged six months. Determinants of exclusive breastfeeding in wāhine Māori are knowledge of breastfeeding recommendations, return to work, motherhood experience, connection to Māori cultural traditions/practices, antenatal depression, and vaccine indecision. Proposed New Zealand health system reforms aim to honour Te Tiriti o Waitangi principles and address the legacy of colonisation, poverty, and systemic racism on Hauora Māori. These reforms should allow the development of breastfeeding policy and interventions that acknowledge and redress the damage that breastfeeding policies have historically had on Māori. Interventions delivered within a kaupapa Māori framework will best address breastfeeding inequities in New Zealand. Health equity for Māori has the potential to improve health outcomes for all New Zealanders.

View Appendices.

Summary

The findings of this research can be used to inform future interventions to protect, promote and support Māori in exclusive breastfeeding. Aotearoa New Zealand is not meeting global nutrition targets for exclusive breastfeeding of infants until six months. While nearly all non-Māori women and wāhine Māori start breastfeeding, only 17% of non-Māori and 12% of wāhine Māori continue to exclusively breastfeed for the recommended six months. Breastfeeding is a fundamental aspect of tikanga Māori (Māori cultural traditions/practices) requiring protection and promotion. Interventions delivered within a kaupapa Māori framework will best address breastfeeding inequities in Aotearoa New Zealand. Mothers who felt that returning to work would limit breastfeeding were less likely to carry on exclusively until six months. Paid parental leave is currently six months, but this will only cover up to about five and half months of baby’s life, and not all women have access to paid leave.

Abstract

Aim

Breastfeeding is a fundamental aspect of tikanga Māori(Māori cultural traditions/practices) requiring protection and promotion. This studyidentifies determinants of exclusive breastfeeding in wāhine Māori (Māori women).

Method

Wāhine Māori enrolled in the Growing Up in New Zealand child cohort study participated (n=1060). Exclusive breastfeeding duration was self-reported. Hierarchical regression analyses were framed by a model of Māori health and wellbeing.

Results

Most wāhine Māori initiated breastfeeding (96%), with 12% exclusively breastfeeding for six- or-more months. Wāhine Māori had increased odds of exclusively breastfeeding for six-or-more months if they: thought it best to breastfeed for >6 months (adjusted odds ratio (aOR)=1.94, 95% confidence interval (CI)=1.05-3.78); thought returning to work would not (aOR=2.17, 95% CI=1.17–4.24) or may (aOR=4.25, 95% CI=1.86–9.85) limit breastfeeding; were experienced mothers (aOR=2.55, 95% CI=1.35–5.06); or were undecided about vaccination (aOR=3.16, 95% CI=1.55–6.39). Exclusive breastfeeding for six-or-more months was less likely if mothers experienced depression during pregnancy (aOR=0.47, 95% CI=0.20–0.99) or viewed cultural traditions/practices as “fairly important” (aOR=0.53, 95% CI=0.27–0.99), compared to “very important”.

Conclusion

Determinants of exclusive breastfeeding in wāhine Māori are knowledge of breastfeeding recommendations, return to work, motherhood experience, connection to Te Ao Māori (Māori worldview) and tikanga Māori, antenatal depression and vaccine indecision. Interventions delivered within a Kaupapa Māori framework will best address breastfeeding inequities in Aotearoa New Zealand.

Author Information

Denise Bennett: Paediatrician, General Paediatrics, Kidz First Hospital, Counties Manukau District Health Board, Auckland. Catherine A Gilchrist: Lecturer, Department of Paediatrics: Child & Youth health, The University of Auckland, Auckland. Rochelle L Menzies: Research Fellow, Koi Tū: The Centre for Informed Futures, The University of Auckland, Auckland. Matire Harwood: Associate Professor, Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland, Auckland. Te Kani Kingi: Professor, Te Mata o te Tau, Ngā Pae o te Māramatanga – The Academy for Māori Research and Scholarship, Massey University. Polly Atatoa Carr: Associate Professor, National Institute of Demographic and Economic Analysis, Faculty of Arts and Social Sciences, The University of Waikato, Hamilton; Growing Up in New Zealand, The University of Auckland, Auckland; Centre for Longitudinal Research – He Ara ki Mua, The University of Auckland, Auckland. Susan Morton: Professor and Director, Centre for Longitudinal Research – He Ara ki Mua, The University of Auckland, Auckland; Growing Up in New Zealand, The University of Auckland, Auckland. Cameron C Grant: Professor of Paediatrics, Department of Paediatrics: Child & Youth health, The University of Auckland, Auckland; Growing Up in New Zealand, The University of Auckland, Auckland; Centre for Longitudinal Research – He Ara ki Mua, The University of Auckland, Auckland; General Paediatrics, Starship Children’s Hospital, Auckland District Health Board, Auckland.

Acknowledgements

Most importantly, we would like to acknowledge the children and the families who are part of the Growing Up in New Zealand study. We would also like to acknowledge the initial funders, in particular the New Zealand Ministry of Social Development, supported by the Health Research Council, as well as the ongoing support from Auckland UniServices and The University of Auckland. The funders played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; nor the decision to submit the manuscript for publication. We acknowledge all the members of the Growing Up in New Zealand team, including those members and managers of the operational (in-person and computer-assisted telephone interviewing), data, communications, community, and quality aspects of the study. We acknowledge the ongoing support and advice provided by our Kaitiaki Group and our national and international Expert Scientific Advisory Group. We also acknowledge the members of the Morton Consortium responsible for planning and design of this study in the Development Phase. We thank Sarah-Jane Paine (The University of Auckland) for data analysis guidance.

Correspondence

Professor Cameron Grant: Department of Paediatrics: Child and Youth Health, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Wellesley Street, Auckland 1142, New Zealand. +64 9 923 6192.

Correspondence Email

cc.grant@auckland.ac.nz

Competing Interests

Nil.

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