Addressing Difference: Mäori Infertility & ART
6.7 Policy Issues
Chris Cunningham (Hui Whai Maramatanga Whai Oranga & Ministry of Mäori Development, 1995:28) argues that the sharp drop-off in fertility rates for Mäori women should be of concern and may lead to increased demand for ART services by Mäori. However, Teresa Wall (Senior Analyst, Mäori Health Branch, Ministry of Health) questions the need for public investment in high cost technologies at the expense of preventative measures.
Preventing the problem at the outset or putting in place high cost technologies? For Mäori it should be identifying whether there is going to be a problem in the future and I suspect that there will be, because of the reports that we are getting now about the higher chlamydia rates. We need to be combating that as opposed to putting in place high cost technologies, which may not be [effective]. Mäori will have problems getting [access to] them irrespective, because of targeting and because its perception that it is not an issue.
(Teresa Wall, Interview: 24 July 2000)
Similarly, Penny Ehrhardt, (Policy Analyst, Te Puni Kökiri) stressed the need to focus on preventative approaches to reduce the need for ART in the future.
The need to protect fertility … seems more of a priority because of [sexually transmitted infections] etcetera, are high and the recent research that has come out that they seem particularly high among young Mäori women, and therefore issues of infertility may become greater issues in the future. The hope is to take a preventative approach at this stage rather than focus on down the track helping a lesser number if possible. (Penny Ehrhardt, Interview: 25 July 2000)
Most of those interviewed argued for improved educational programs that would inform young people on how they could best avoid exposure to fertility risks. Similarly, Blank and Merrick (1995:221-222) suggest that more resources spent on preventative measures for the known causes of infertility and research into the causes of unknown infertility would better assist marginal groups than increased spending on ART innovations. However, those young Mäori women who have already been exposed to fertility threatening STI’s are likely to face the barriers mentioned to accessing ART services in the near future and prevention focused policies will not assist them. Regardless of resources devoted to preventing infertility, there is a need to examine how ART services can better assist Mäori people who are already experiencing fertility problems.
The exclusion or marginalisation of Mäori within the policy discourse surrounding ART practices is not necessarily a deliberate strategy implemented by policy-makers, providers, and consumers. According to Iris Marion Young (1990:185), “policy issues are often defined by the assumptions and priorities of the privileged.” Groups with social and economic privilege have the “material, personal, and organisational resources” that facilitate their ability to express their needs and priorities so that they are seriously considered (Young, 1990:185). As such, and
without specific information on the use of ART by Mäori, ART policy continues to be based on the perceived needs of the culturally dominant Päkehä group. This is not to say that providers are unaware of the barriers to services that Mäori face. Some are already trying to accommodate cultural diversity and improve their services for Mäori.
It is very hard because there is not a Mäori voice to go to you know. We have used Mäori people and we have used particular feedback from patients to try to be more sensitive and to try to think and deliver a better way….
(John Peek, Interview: 12 July 2000)
Similarly, Rodney Bycroft (Scientific Director/Manager, Artemis North Shore Fertility, Auckland) acknowledges the need for cultural sensitivity in relation to ART practices.
…the relationship we have with other cultural groups needs to be recognised. I would say that would include, in Auckland because it is such a cosmopolitan city now, Chinese, Asian, Korean, Indian, Pacific Island, you name it. That means that we have to have access to interpreters, we have to be culturally sensitive to their requirements, and the specific issues of whänau and iwi and consultation with hapü and their elders. … And, I believe that that consultation process is vital to some of the specific issues of [certain] ethnic groups.
(Rodney Bycroft, Interview: 13 September 2000)
While these clinics have indicated a willingness to consult with Mäori about how they can better improve their services and make them culturally safe, as stipulated in the service specifications (Health Funding Authority, 2000b:2, see Appendix L), it appears that there are no sanctions implemented regarding non-compliance. The conditions imposed by the service specifications for publicly funded ART require clinics to implement a Mäori health policy that recognises “that Mäori health is a specifically identified health gain priority area” and to “identify how these services will be measured to ascertain what benefit is evident and any other additional opportunities that may exist for furthering Mäori health gain” (Health Funding Authority, 2000b:2, see Appendix L). However, there are no specific procedures outlined to assist clinics in developing and implementing this policy and, although providers are required to submit their plan within three months of the implementation of the service specifications, there is no guarantee that the Ministry of Health will follow up or enforce these plans anymore than the HFA implemented the data collection requirements of the previous contracts.165
Young’s (1990:158) politics of difference promotes “equality as the participation and inclusion of all groups” and argues that, as such, “it sometimes requires different treatment for oppressed or disadvantaged groups.” Accordingly, social policy should recognise that certain groups have particular needs and should target these groups for specific treatment. While the Ministry of
165 In January 2001, the HFA’s functions were integrated into the Ministry of Health and District Health
Health recognises that Mäori are particularly disadvantaged in the health arena and address this issue through the inclusion of Mäori focused policies, the inequalities in access appear to have low priority in relation to ART. This is perhaps influenced by the perception of ART and infertility treatment as a “niche” area, mainly utilised by the white middle classes. However, some Mäori do use ART and, although the policy discourse that does exist in relation to the use of ART by Mäori articulates a need for ART practices to be culturally safe, what these requirements might be are not explicitly laid out. The formulation of adequate policy in relation to Mäori and the use of ART must start with the collection of information, addressing issues such as whether technological solutions to infertility are appropriate or acceptable for Mäori and what issues need to be addressed to make ART practices culturally safe. As John Peek (Clinical Manager/Group Operations Manager, Fertility Associates Auckland) acknowledges,
…we still do not know what proportion of Mäori feel comfortable using ART as an approach to infertility and what proportion [are uncomfortable with it].
(John Peek, Interview: 12 July 2000)
This raises a point made by Penny Ehrhardt (Policy Analyst, Te Puni Kökiri) in relation to finding out what Mäori see as the main issues regarding the use of ART.
The other point to make in terms of Mäori input, if [the Ministry of] Health or anyone was going to do a look at ART [or the] guidelines, we feel it is important that they actually go and ask Mäori what they see as their priority. … Not necessarily door knocking, maybe going to Mäori organisations. Te Puni Kökiri does not speak for Mäori. (Penny Ehrhardt, Interview: 25 July 2000)
Reid (1999b: 89) argues that it is important to recognise that “Mäori are a diverse population, expressing ethnicity across a spectrum of realities, from conservative to modern and tribal and urban.” There is no one Mäori voice to articulate the needs of Mäori; nor is there one Mäori reality. As Durie (1998:215) and others (Cunningham & Kiro, 2001:68) have pointed out, Mäori inhabit varied cultural worlds. Tobias (2001:21) argues that the “ethnic experience is different for males and females, for people living in different parts of the country…, for people of different birth cohorts ageing through different periods…, and for people belonging to different social classes.” Similarly, Dame Joan Metge (in New Zealand Law Commission, 2000:84) contends that “many urban Mäori are alienated from their cultural heritage and may be more comfortable with Päkehä views and practices.” Accordingly, those interviewed in relation to Mäori infertility and the use of ART (Glavish, Wall, Peek, Ehrhardt, and Allan) emphasised or reiterated the point made by Grant Allan (Senior Policy Analyst, Te Puni Kökiri).
You cannot just generalise the opinion of one Mäori to another.
(Grant Allan, Interview: 25 July 2000)
Although Crown objectives concentrate on reducing inequalities between ethnic groups, Cunningham and Kiro (2001:68) argue that the increasing disparity within the Mäori population
is of equal importance and that health policy must allow for heterogeneity in relation to cultural experience, health status, and expectations with regard to outcomes. However, Naida Glavish (Chief Advisor - Tikanga, Mäori Health Development Service, Auckland Healthcare Services Limited) argues that at present all health services
…are basically homogenous and are ill equipped, bordering on incompetent, to deal with the heterogeneous and accepting difference. All the structures are designed for that homogenous psyche basically.
(Naida Glavish, Interview: 9 August 2000)
Recognising that Mäori are a diverse group of people whose needs and values are varied and complex highlights the difficulties surrounding policy formation. Teresa Wall (Senior Analyst, Mäori Health Branch, Ministry of Health, Interview: 24 July 2000) argues that investment in the notion, if not the belief, of a homogeneous population was a way of simplifying policy formulation. She maintains that catering for the diversity of human relationships within the policy framework is too difficult and that a uniform a notion of family is easier to manage at a policy level.166 Young (1990:174) argues that affirming ‘difference’ may produce stigma and
exclusion and highlights past strategies where “group-conscious policies were used to separate those defined as different and exclude them from access to the rights and privileges enjoyed by dominant groups.” However, the assumption of homogeneity within groups as a policy strategy will also continue to disadvantage those who do not fit the accepted norms and standards associated with that group. The marginalisation of Mäori in the existing ART policy discourse appears to be based on the belief that “…Mäori don’t access it” (Helen Williams, Policy Analyst, Elective Services Project, Health Funding Authority, Interview: 29 August 2000) and that Mäori may have other ways of dealing with infertility. These assumptions are direct results of the lack of information available about the prevalence of infertility and the ethnic composition of those already accessing ART treatments.
6.8 Conclusion
While exploring ART policy and its impact on reproductive choice in Aotearoa/New Zealand, I was unable to locate any significant documentation or policy initiatives relating to Mäori use of ART. Specific concerns had been raised by Manatu Mäori (Ministry of Mäori Affairs) (MCART, 1994: Appendix E) about the protection of whakapapa and the use of culturally supportive and safe ART practices. However, there appeared to be no research into whether these concerns
166 See Chapter One, Introduction, Section 1.4, Families & ART, for a detailed discussion about this in
continue to be of relevance. In general, interviewees offered little insight into Mäori specific policy responses to ART practices. Consequently, the focus of this chapter became the silences in the ART policy discourse in relation to Mäori, as well as the issues raised by the interviewees about the prevalence of infertility in the Mäori population, the barriers Mäori encounter to accessing health services, and the collection of information on ethnicity within the health system.
There is no data available with regard to the prevalence of infertility in the Mäori population of Aotearoa/New Zealand. Neither is there any quantitative information about the utilisation and access of ART services by Mäori. However, high rates of reproductive system disorders and exposure to sexually transmitted infections by young Mäori women, as well as changing characteristics in relation to Mäori women’s childbearing patterns indicate that there may be an increasing demand for ART services by Mäori women in the near future. As Mäori women and men generally hold lower socio-economic status than non-Mäori women and men, they are more likely to encounter barriers to accessing ART services. These access barriers include financial costs and geographic location, as well as experiencing cultural insensitivity and discomfort in mainstream health services. Similarly, obstacles experienced in relation to the take-up rates of other social assistance schemes may also influence the take-up rate of publicly funded ART treatment. Lack of entitlement awareness, stigmatisation, privacy issues, abatement rates, and the time costs may all contribute to the inability or unwillingness to access publicly funded treatment.
Until accurate quantitative data is available in relation to who actually accesses ART services, it will be impossible to accurately identify the needs of Mäori in relation to infertility treatment or to effectively evaluate and monitor the State’s health policy outcomes. Although HFA contracts require fertility clinics providing publicly funded fertility treatment to retain information on the ethnic composition of ART consumers, this requirement is not enforced and, as yet, there is no evidence that the newly instigated health sector restructuring will alter this situation. Difficulties in defining Mäori and the use of ethnicity as a variable in social research further complicate the collection and generation of statistics in relation to Mäori infertility and access to ART services. Inconsistencies in defining ethnicity and the inability to make comparisons across data sets, as well as the use of statistics to engage in negative comparisons of Mäori and non- Mäori, have all contributed to a distrust of data collection in relation to Mäori by some commentators. Nevertheless, until accurate statistical data are available, ART related policy will continue to be based on historic demands and influenced by the perceived needs and welfare of
the culturally dominant Päkehä population. As such, those who do not have the social or material resources to compete for scarce resources in this area will continue to be marginalised. Several commentators have suggested that the use of whängai is a culturally acceptable alternative to ART treatment for infertility and others have equated whängai to surrogacy. Although it is possible that surrogacy is more acceptable to Mäori than other ART practices because it shares some characteristics with whängai, there is no empirical evidence to support either of these suppositions. While there is undoubtedly a diverse range of definitions associated with the practice of whängai within Mäoridom, it is perhaps more suitable to associate whängai with the Päkehä concept of fostering or guardianship or the increasingly acceptable concept of ‘open adoption’. Although whängai may be an appropriate alternative to ART for some Mäori, it cannot be presumed that it is an acceptable or even feasible solution to infertility for all Mäori. Mäori men and women do currently use ART services and this raises important issues in relation to the protection of whakapapa. Even though there has been a move towards a culture of openness in relation to donor insemination and adoption in Aotearoa/New Zealand, this is not a legal requirement. Access to information is dependent on parental openness about the circumstances of their children’s birth and the availability of accurate information. Legislation continues to promote secrecy through the provision of a ‘false’ birth certificate and, although RTAC requires that some records be kept by accredited clinics, they are an Australian based committee that, as yet, does not include an Aotearoa/New Zealand-specific supplement to their ‘Code of Practice’. Therefore, the lack of legislation to promote and guide the collection of ethnically relevant information means that Mäori involved in donor ART practices must continue to rely on clinical discretion to ensure that knowledge of whakapapa will be permanently available.
Rather than speak for members of another ethnic and/or cultural group, my intention was to highlight what I perceive to be the silences surrounding the use of ART by Mäori in relation to policy issues. ART innovations and applications will continue to advance and, as highlighted earlier, there may be an increasing demand for ART practices by Mäori people. However, the ability of Mäori to access ART will continue to be severely constrained by the lack of information about the prevalence of infertility experienced by Mäori and the continued policy emphasis on the needs of the dominant cultural group in Aotearoa/New Zealand. By positioning infertility as a white middle class problem and contending that ART is not an option considered by Mäori people with fertility problems, policy-makers and commentators ignore barriers to access that may effect take-up rates by Mäori and low-income groups. Consequently, the take-up rate is
presumed to be a reflection of the need rather than a symptom of inequality in access and policy. However, increasing recognition of Mäori as a diverse group of people with varied needs and values will continue to undermine the homogeneous focus of most policy initiatives and may accentuate the need for Mäori-specific access policies to overcome the inequalities and barriers they experience in relation to the health system. This chapter does not presume to recommend how Mäori might wish to address policy issues surrounding access to and the provision of ART services for Mäori. Nonetheless, it does highlight a need for more research into the barriers Mäori experience in relation to accessing ART treatment for infertility. It also emphasises the need for more information gathering in relation to the use of ART practices by Mäori so that future policy can accurately provide for the needs and interests of Mäori individuals without assuming that they correspond with the needs and interests of the equally diverse dominant Päkehä group.