Series 2 Episode 2: Donna Cormack on transformation for Māori health

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INTRO — Hi everyone. You’re listening to Birthing and Justice: a series of conversations about birth, racism and cultural safety. I’m Doctor Ruth De Souza and today I’m speaking to you from the unceded sovereign lands of the Boonwurrung people of the Kulin Nations. I’m here as an uninvited guest and I pay my respects to all the Elders and Warriors who’ve resisted colonisation, invasion and genocide, and who share Country with all of us. This land always was, and always will be, Aboriginal land. Today I’m joined by my dear friend and colleague Donna Cormack. Donna’s Kai Tahu and Kāti Mamoe, she’s a researcher and teacher at Te Kupenga Hauora Māori, at the University of Auckland, and at Te Rōpū Rangahau Hauora a Eru Pōmare. I’ve been a big fan of Donna’s very thoughtful transformational work. We wrote something together way back in 2009 and I’ve been itching to do something with Donna again. I’m so happy that we get to talk today about a topic that is deeply important to both of us: racism. We’re going to talk about representations of Aotearoa as a model for other settler nations, obstetric violence, monitoring for equity, and much, much more. And before we get started, just a reminder that parts of this conversation may be distressing for some listeners. So let’s get into it.

 

DONNA CORMACK (guest) — I think I care about birthing because I want a future that’s different, and I imagine a future where our tamariki and our mokopuna are well, and a future that’s sovereign, and where their time is taken up with joy and laughter and creativity and celebration. Inequities waste so much time and energy for our communities and I just think about all the things that we could be doing, that our mokopuna will be able to do if they don’t have to focus on this. And so I think that’s a driver. What can I change with the time that I have, and the resources and space that I have, to mean that there’s less work for them to do? I guess more broadly what we see in pregnancy-related outcomes, and in the health of parents and babies really reflects the inequities that exist for Māori across the whole health sector. And I think it’s interesting ‘cause they play out also in really specific gendered and heteronormative ways in this space. And I’ve been influenced more recently through sort of prison abolitionist theorising, because I think, seeing how some of those carceral logics and that policing of pregnancy and birthing—policing of peoples’ bodies and peoples’ practices around pregnancy and childcare—what we can learn from abolitionist theorising that can help us reimagine birthing and pregnancy care, outside of that kind of carceral logics. So I think that’s what keeps me interested in this space.

 

RUTH DE SOUZA (host) — So much, Donna. And in my own work there’s been concern about the ways in which differently raced bodies are surveilled, and their practices that maintain health are pathologised. So many people hold up Aotearoa as being this kind of beacon of how things should be in settler colonial societies. And I’m kind of wondering about, you know, whether you could tell listeners about your work—we’re going to talk more about pregnancy soon—but I’m wondering whether you can tell them about your work and perhaps also some more about how abolition and anti-racism come into this mahi?

Yeah, I think you’re right, we do hear sort of narratives about how well Aotearoa is doing, relative to other societies. And I agree that those are quite limited, and their usefulness in sort of acting against racism. I’ve found some of the decolonial theorising around understanding racism as a global, or a world system, has been really helpful for this. So understanding that it operates globally, and it might play out in different ways, or particular ways in different settler colonies, but we’re all part of this global world system of racism, and its sort of attendant systems of oppression—like capitalism and heterosexualism. And so I think the comparisons are not always that useful if it’s trying to sort of rank us in terms of oppression. But I do think that there’s a lot of strength and solidarity in Indigenous people’s working together across sort of settler colonial nation states, to share resources, and to work together, from our particular locations in this global system. I think we have been able to have more detailed, and more comprehensive data in Aotearoa than I know has been the case for Indigenous peoples in other nation states. That’s a little bit of a two-edged sword sometimes, that allows us to do more monitoring, but it also can be used or weaponised against us. So I’m aware of how data can be harmful, but I know talking with colleagues in other countries that often even being able to count or measure what’s happening for their communities is, like, a real struggle. So perhaps that’s one area where I see that, relatively speaking, we might be doing better. But I think some of Tina Ngata’s work, and Veronica Tawhai and other people who have really exposed a lot of what has happened in Aotearoa New Zealand’s history, has been really important in sort of combating that myth that things were pretty good here—things that happen overseas didn’t happen here. And so there’s a lot of unlearning for us to do in Aotearoa, as well as sort of unlearning some of those myths overseas as well.

 

Thanks Donna. As you were talking I was also thinking about some of the work that you’ve been trying to push—and I’ve heard this mainly via Twitter—around having data on vaccination during COVID, and I wondered if you could tell us a little bit about what’s been happening in that space?

Yeah. One of the things that has been really frustrating—and it goes back to that point I made at the start, wastes a lot of time and energy—is that we’ve had this real high-level rhetoric around equity throughout the COVID pandemic, but we’ve had to kind of battle at every step of the way to get any sort of timely data that’s useful for communities to be able to understand how both the pandemic, and the pandemic response, are impacting our communities. So we have this funny situation—it’s not really funny, it’s a racist situation—where we have a lot of data collected about us because we are over-surveilled as a population, but then a real slowness to use that data in ways that actually support self-determination, or Māori communities being able to understand and act on the priorities for our communities. Like our vaccination roll-out started in February, and I think our first ethnic-specific rates were published in early August. And it’s not because the data’s not there. And there are a lot of issues around the quality of the data and decisions that were made around which data sets to use, but even with all those caveats, how can you say you’re doing something equitable if you’re not actually even monitoring for equity as you go along?

 

Yeah, absolutely. You’ve recently retired from the Perinatal and Maternal Mortality Review Committee [PMMRC] and you’ve pointed out some of the inequities that you’ve flagged a little bit just now. But we know that there’s significant Māori maternal health inequities which include: higher mortality, increased likelihood of having caesareans, differences in access to care, differential exposure to health damaging factors and environments, and of course there have to be corresponding inequities for Māori’ pēpē also, which include: a higher proportion of low birth weight babies, higher perinatal mortality. Can you tell us a little bit about how, as a scholar of racism, you’ve tried to sort of impact both on practice and policy, and you know, how being on this committee is part of that attempt to transform systems?

I think what I wanted to achieve while I was on the committee was really trying to make sure that when we were monitoring outcomes, that we were always presenting data in a way that was really contextualised within the current context, but also the historical context. So that monitoring didn’t become about sort of individual people and their choices, or health behaviours or health risks—you can’t see me on a podcast, but I’m using scare-quotes around “behaviours and risks” [Ruth laughs]—and really that we were always producing, ah monitoring data that was deeply, deeply contextualised in what we know about society. So that we would always be able to understand that these racialised inequities are playing out because we have a society that is deeply racist and colonial. So they’re not a surprise in that sense, but they’re also not inevitable—they’re created and maintained by systems of oppression that don’t have to be. And so I think that was… what I was hoping to achieve was to focus as much on the sort of root causes and the fundamental drivers of these inequities, as a sort of surface level causes. We’re really limited often in what we can say about those root causes because our system is not really designed to capture information about its own performance, or about the performance of providers, let alone more broadly about structural and societal determinants of health. And so often when we’re monitoring health outcomes we end up only being able to look at factors about an individual—variables about them, often not even reported by them but reported by other people about them. And so that can lead us down really victim blaming deficit thinking. And so I think if there’s value in monitoring, we have to think really deeply and carefully about the risks of continuing to kind of monitor without really deep contextualisation of that data, and what it represents is really an expression of broader societal systems of oppression. You can probably see some of my ambivalence coming through around monitoring, because that was one of the things I struggled with on the PMMRC is: what is the place of monitoring and equity, and worrying about whether or not it actually is a non-performative. So influenced here by Sara Ahmed’s work around sort of the non-performativity of racism. And she talks about what we don’t do with words, and I feel like sometimes it’s what we don’t do with numbers. So the monitoring of the inequity becomes seen as the action…

 

Exactly!

rather than, it’s just a kind of a witnessing, or a putting on record—we know what’s happening, and you know what’s happening, but the action has to then follow. That’s something I’m still thinking through, what place does monitoring have, sort of in an anti-racist, anti-colonial response, and worrying that, yeah people will stop at the monitoring and not realise that that isn’t actually the action for change.

 

Absolutely, absolutely. I love that work [laughs] so much. Let’s talk a little bit maybe about privilege and racism. Who benefits from the health system that we have in Aotearoa, and why should racism be a concern for perhaps all users of the health system?

Yeah, and I think that’s one thing that we’re not good about always, when we do do research around racism, or monitor around racism. And part of that is again because we tend not to have data on privilege in the same way as we have multiple sort of indices of deprivation or disadvantage, and so it becomes hard to monitor that privilege. And I’m thinking here of some of the work that Belinda Borell and colleagues have done around kind of trying to flip the gaze onto privilege in the health space. But obviously under a racialised, colonial, heternormative system, the closer you are to those sort of, to whiteness, to heteronormativity, the more you’re going to benefit from a system that’s designed with those values and logics embedded. One of the things that we often do is we look at, kind of the scarcity of resource side, and we’re not as good at looking at overconsumption. And so I’m really interested in that, in health care and the way capitalism plays out both in denying people accesses to resources through either an actual or a manufactured scarcity. But the way in which other people are overconsuming, that there’s a reward under capitalism for the overproduction and overconsumption of resources as well. So you’ve got, not only some people are not getting access to required, adequate, appropriate care, there’s also an overconsumption at play, and we don’t often kind of look at that. And so that’s where I get a little cynical, I think, about how far we can get with some of the current health system reforms that are being talked about and proposed in Aotearoa, is that we haven’t really engaged with the role of capitalism in structuring, and kind of reproducing the health system that we have, and that maintains both scarcity—real or imagined or performed scarcity at one end, and this sort of overconsumption, overproduction, wastage, at the other end.

 

Such a good point. And as you’re talking, I was also thinking about how heterosexualism has started to become part of your analytic frame. Can you tell us a bit more about that?

It’s probably because I read a brilliant paper yesterday, from Australia, from Madi Day, around heterosexualism. So I think I’ve always been really interested in the way that gender and patriarchal, heteronormative values and logics play out in this birthing and pregnancy space. But I’ve found reading a little bit more yesterday and following some of the references in the paper by Madi Day around heterosexualism really useful to think about how it plays out in settler colonies—so feeling a lot of similarities through the discussion in that paper around Australia with how it plays out here in Aotearoa New Zealand. And thinking that’s something that we have to come to terms with in this space: we still have a lot of gendered language, we still have a lot of sort of assumptions around what’s right, or appropriate in this space, that are really very colonial and racialised ways of thinking about pregnancy and birthing. And that’s something that I think a framework like heterosexualism or other ways of, you know the coloniality of gender and those sort of frameworks, can really help us think through, so that we have a system that’s much more inclusive and respectful of all the different ways of being pregnant and ways of birthing.

 

Yeah, absolutely Donna. And that’s something I’m hoping to cover in future podcasts. Because the language has changed so much since I did my PhD and I worked on post-natal wards, and it’s so inadequate. But it’s kind of my default, and I’m in that process of trying to unlearn and relearn, you know, more expansive ways of talking about this whole field. You know, my PhD was called Migrant Maternities, and it’s like, even though it was trying to focus on the bodily experiences of birth, and the coagulations of power so to speak…

Mmm.

 

it was also then being quite exclusive. You know now…

Yep.

 

eleven, twelve years later it seems just so exclusive, yeah.

Yeah and I think we really need to talk about that more, in this space.

 

And at a very basic level it’s also about things like: who is a family? What constitutes a family? you know, all of that.

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I think many of the stereotypes that exist around pregnancy-related outcomes and birthing—particularly around differences in pain tolerance or expression of pain, or judgements about sexual and reproductive health—are really long-standing ideas. And we can kind of trace back through the history of, sort of an imposed colonial model of healthcare in Aotearoa, and see how persistent these narratives and discourses are. And I’m always interested in how those stereotypes both continue—and we do hear people still drawing on employing those racialised narratives about pain tolerance or pain expression, among different ethnic groups—but we also see this inequitable access to pain relief, both more broadly but also in maternity care. So I wonder how those stereotypes are playing out in sort of material ways, those long held beliefs about pain, in sort of ways… in the current context of the provision of adequate pain relief. And I think part of that is we’ve… I don’t know if it’s a hesitancy, or I think I categorised it before as a deliberate unremembering or disremembering, or misremembering of the history of the discipline and how it’s a racialised and gendered history, and it’s also quite a violent history, in terms of how particular gynaecological and obstetric practices and procedures and services were developed. And I think that we don’t do birthing and pregnancy care a service if we’re not prepared to engage with that history, and reckon with the ways in which it still plays out in our provision of care. So here in Aotearoa you don’t need to think too far back to the Unfortunate Experiment at National Women’s Hospital, but also recently, you know people talking about unconsented vaginal examinations happening under anesthesia, what happens to incarcerated women during labour in prisons, and you know, the taking of Māori babies by the state, including from, you know birthing wards. So the history is now, and we really need to engage in this space if we don’t want that history to continue on into the maternal, pregnancy-related birthing space in the future. I just feel that there’s not a willingness to really engage with that, and I think we can’t imagine a better care system if we don’t reckon with where the one we’ve got came from, in an honest way.

 

Absolutely, it’s that whole kind of issue around truth telling acknowledgement of the past in order to build that kind of future that we started off…

Yeah.

 

talking about Donna, where you talked about, you know flourishing, rather than using up all this energy trying to address racism.

Yeah.

 

And I kind of wonder about how you look after yourself with this unrelenting kind of work. Can you tell us a little bit about your self-care. I kind of hate that term as well as finding it useful, you know. [Laughs]

Yeah, no, and I understand it how you’re using it, in a sort of collective self-care, rather than a very sort of neoliberal, individualistic self-care way. I mean at first it’s really, I guess important for me to acknowledge that in a lot of ways I am protected a lot from the systems of oppression that I’m talking about. I whakapapa Māori, and I identify as Māori but I present as white, so as, you know someone who’s read in most social interactions as white, straight, cis-gendered, I can do the work with a degree of already protection built in, that is not afforded to other people doing this really important work too. So I do want to acknowledge that. But in terms of self-care I read a lot—I find a lot of joy in reading—I love food, cooking and eating. I think also, this is a space that is frustrating and I do get angry, and I feel exhausted and drained, but it’s also a space where I’ve made some really deep, long-lasting friendships. And, particularly I think in being privileged to work with amazing students, and you know scholars who are pushing boundaries and creating spaces that were not there when I was there, that actually is really sustaining and gives me a lot of joy, being able to walk alongside people on those journeys. So yeah, I think that’s probably… donuts and tetris are probably my other [giggles] kind of self-care.

 

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When we talk in this space—particularly when we talk to people in, sort of the prevailing health systems, health providers—there’s sometimes this response of, I think I’ve been thinking about it as like a learned helplessness, or a performed helplessness, where people say ‘Oh it’s too big, it’s this… racism, I can’t do anything about that I can’t address it, I have no power or authority within the system.’ And here I’m talking about people who are… ones who are benefitting from the current systems of oppression, not people who are being oppressed by those systems. And so it’s really… I think that’s part of that claim to white innocence, this idea that I can’t do anything because it’s a big problem, rather than thinking about all the different ways that daily you can work towards transformation. So alongside sort of advocating for dismantling those systems of oppression at a societal level, there’s things that you can do everyday in the systems and places that you’re in, to work towards a change that makes the system better for everyone. So I guess I get tired or frustrated with that sort of performed helplessness because there’s a role you can play where you are, even if it’s only learning and unlearning yourself, to contribute to something that’s better.

 

Yeah it reminds me of that term Pākehā Paralysis that used to get used a lot. You know it’s like ‘Oh it’s too big, it’s too hard, I’m overwhelmed.’

Yeah.

 

And also a kind of disavowal or not owning power that people have, and…

Yep.

 

that’s where my work has been, it’s like saying: actually nurses are very powerful but they feel marginalised by managerialism and biomedicine, but actually in every moment there’s an opportunity to kind of intervene in a way that’s equitable, fair and mana enhancing.

Yeah. And that that’s work and not just a job, and that’s work that has to happen in your kind of work settings, but also it’s work that we have to do as part of dismantling colonialism and racism more broadly in our societies. So it has to become not a one-day unconscious bias training session, it has to become work—everyday work, towards transformation.

 

And maybe a question around abolition and how that’s informing how you do things?

So I think abolitionist theorising, and I… here I’ve probably been reading and influenced by Associate Professor Ruha Benjamin’s work from the US, as well as Ruth Wilson Gilmore and Angela Davis talking about, in that prison abolition space, how we need to be actively refusing the systems that are, you know violent and destructive, rather than getting struck in that kind of incremental reform space—making things a little bit better. I’m not saying that we shouldnt mitigate harm where we see harm happening in current systems, that we shouldn’t be trying to make things better, but to me, it has to be part of a broader commitment I guess to actually getting rid of the structures and systems that should not have a place in our society. And so I think that’s where abolitionist theorising has given me some language around that, and ways of understanding, and a real encouragement to imagine things differently; even if we can’t exactly put into words what that different might be, that we know that there’s a radical alternative possibility that will be much, much closer to what our mokopuna deserve, than the systems that we have now. And I think abolitionism… I like the space of refusal, and here I’m really influenced by Eve Tuck and Wayne Yang’s writing around refusal, and they talk about refusal as generative because it’s both a yes and a no—so when you’re saying no to something, space opens up for other possibilities. And I think that’s something we have to do more in these spaces, is not always put energy into trying to fix a system that’s only ever going to deliver in a certain way. And there might be value in that system for particular groups of people, or particular health outcomes, but we all have to be putting more energy I think into the yes of the alternative radical system. And I think in this space, thinking around epistemic injustice is really important too. And again it’s that kind of interplay of the gendered and racialised nature of the dismissal of knowledge around birthing and pregnancy in our current health systems, and who’s considered, you know, a credible knower of their own body, of their own pregnancy, of their own birth. And how Māori practices of healing and sexual and reproductive health have really been dismissed—and still are to a large extent—within current systems. And like, what would an alternative system look like, and what would that open up in terms of a… you know, a transformative, radical birthing system for Māori. I’m not saying that some of those practices, those alternative practices are not happening already, but I guess that’s my thinking too when we engage with this sort of critique and monitoring of the current system, not getting caught in using too much of our energy in that space rather than the creative space.

 

Tweaking.

Yeah, we get a bit focused sometimes on trying to make those little changes.

 

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It’s been great talking to Donna today, and even though her work highlights the tremendous challenges both for Māori, and for allies working for equity, I feel hopeful about what we can collectively do to make birthing more equitable. So thanks Donna for sharing your work with us.

 

OUTRO — You can find more episodes, transcripts and links at ruthdesouza.com/podcast. I’ll add some links to Donna’s work there too, and if you enjoyed this episode, chuck us a rating or a review wherever you listen to your podcasts. Next time on Birthing and Justice, I’ll be talking with the amazing Habiba Ahmed: a second generation Somali mother and community advocate working in maternal health, born and based in Melbourne, Australia.

 

Birthing and Justice with Doctor Ruth De Souza is written and hosted by me, and recorded at my home on the traditional lands of the Boonwurrung people of the Eastern Kulin Nations. Sound design and mix by Jon Tjhia, artwork by Atong Atem, design by Ethan Tsang, theme music by Raquel Solier and produced and edited by Jon Tjhia. This podcast is supported by funding from the RMIT University Vice-Chancellor’s Fellowship Program.

 

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END NOTES — Audio transcript edited and designed by Abbra Kotlarczyk, 2022. Note: t­­­­he purpose of this audio transcript is to provide a record and pathway towards accessing all Birthing and Justice conversations. Editorial decisions around the omission of certain words and non-verbal utterances have been made purely for stylistic purposes towards greater legibility, and do not infer a desired ethics of speech.