Tū te turuturu nō Hine-te-iwaiwa: Mana wahine geographies of birth in Aotearoa New Zealand

This thesis examines the embodied, spiritual and spatial experiences of maternity for Māori women. It reveals how colonial and patriarchal discourses are embedded and embodied in the spaces of childbirth in Aotearoa New Zealand. I use a mana wahine (Māori women’s) framework to critique discourses that continue to marginalise and isolate Māori women and their whānau (family group) during their maternity experiences. Importantly, this research highlights the possibilities of reclaiming and reconfiguring mana wahine in both theory and practice. In doing so, I conceptualise new geographies that account for, and celebrate, uniquely Māori understandings and expressions of maternity. Mana wahine provides a much needed theoretical framework that enables Māori women to (re)define and (re)present our lived realities on our own terms. A qualitative mixed method approach of interviews, solicited diary writing and a marae based wānanga is employed to examine the lived experiences of birth for ten first time mothers, five midwives and a wānanga of 17 women and their whānau. In total 32 women participated in various phases of the research. Empirical material is arranged around four key themes. The first considers the ways in which colonialism is lived and embodied in maternity experiences for many whānau. New formations of colonialism are evident in the silence that can surround the maternal body for women in this research. The second theme highlights how whakapapa (genealogy), wairua (spirituality), and whenua (land/placenta), can provide a powerful reconceptualisation of the maternal body that offers new possibilities for thinking about maternal embodiment, the spaces of birth (both material and discursive) and maternity policy and practice. Third, it is argued that many women and whānau occupy a number of in-between maternity spaces as a result of our colonised realities. As such, considerations of space from a mana wahine perspective can serve to destabilise the dualisms that dominate the spatial politics of birth in Aotearoa. Finally, this thesis posits that by reclaiming the collective and spiritual spaces of birth and afterbirth it is possible to transform and empower women and whānau in their maternity experiences. This thesis responds to a scarcity of academic scholarship on mana wahine maternities. It advances mana wahine and feminist geographical knowledges by providing a critical spatial perspective on Māori women’s maternal geographies. It is argued that reclaiming mana wahine maternities has the potential to transform women’s birthing experiences by (re)asserting the tino rangatiratanga (self-determination) of women, of their babies, and of their whānau, and thus the rangatiratanga of Māori communities, hapū (sub-tribe/sub-tribes) and iwi (tribe/tribes)

Mana Wahine Geographies: Spiritual, Spatial and Embodied Understandings of Papatūānuku

This thesis is a theoretical and empirical exploration of Māori women's knowledges and understandings of Papatūānuku in contemporary Aotearoa. The primary focus of this research is on the complexities, connections, and contradictions of Māori women's embodied relationships with the spaces of Papatūānuku - spaces that are simultaneously material, discursive, symbolic, and spiritual. In doing so, I displace the boundaries between coloniser/colonised, self/other, rational/irrational and scientific/spiritual. I demonstrate that Māori women's colonised realities produce multiple, complex and hybrid understandings of Papatūānuku. This thesis has three main strands. The first is theoretical. I offer mana wahine (Māori feminist discourses) as another perspective for geography that engages with the complex intersections of colonisation, race and gender. A mana wahine geography framework is a useful lens through which to explore the complexities of Māori women's relationships to space and place. This framework contributes to, and draws together, feminist geographies and Māori and indigenous academic scholarship. Autobiographical material is woven with joint and individual semi-structured in-depth interviews conducted with nine Māori women in the Waikato region. The second strand, woven into this thesis, is a critical examination of the colonisation of Māori women's spiritual and embodied relationships to Papatūānuku. The invisibility of Māori women's knowledges in dominant conceptualisations of mythology, tikanga and wairua discourses is not a harmless omission rather it contains a political imperative that maintains the hegemony of colonialism and patriarchy. I argue that to understand further Māori women's relationships to space and place an examination of wairua discourses is necessary. The third strand reconfigures embodied and spatial conceptualisations of Papatūānuku. Māori women's maternal bodies are intimately tied to Papatūānuku in a way that challenges the oppositional distinctions between mind/body and biology/social inscription. Māori women's maternal bodies (and the representation of them in te reo Māori) are constructed by, and in turn, construct Papatūānuku. Furthermore, women's spatial relationship to tūrangawaewae, home space and wider environmental concerns demonstrates the co-constitution of subjectivities, bodies and space/place. My hope is that this thesis will add to geographical literature by addressing previously ignored knowledges and that it will contribute to indigenous scholarship by providing a spatial perspective

Honouring our ancestors: Reclaiming the power of Māori maternities

Māori¹ maternal knowledges are intimately tied to ancestors, to ancestral knowledges, and to whenua (land).² Iwi (tribes), hapū (smaller tribal groupings), and whānau (families)³ have their own maternal knowledges, which are woven into their cosmologies, histories, songs, carvings, place names, chants, and incantations. These knowledges, though spatially and temporally specific, speak to the sanctity of the maternal body, the power and prestige of women’s reproductive capabilities, and the empowering collective approach to raising children. Māori knowledges pertaining to pregnancy, childbirth, and parenting were imparted generation to generation as they were lived, embodied and emplaced by our ancestors, sustaining the sacred and empowering approach to maternities within our communities. This chapter considers the challenges and possibilities of reclaiming Māori maternal knowledges and their associated practices and ceremonies for Māori women and whānau in contemporary Aotearoa-New Zealand. Three key themes frame this chapter. First, I consider the ways in which colonialism has served to silence Māori maternal knowledges to such an extent that whānau are left trying to find meaning in the voices, knowledges, and advices of others. Indigenous women are largely birthing within Western ideologies and institutions that do not adequately provide for Indigenous ways of being and birthing. The chapter then considers the ways in which women and whānau are reclaiming ancient knowledges and practices in new and contemporary ways. I seek to illustrate the ways in which traditional practices and ritual customs have the potential to transform and empower individual and collective experiences of birth and afterbirth. The chapter ends with arguing that Indigenous maternities, Māori maternities, are an important site of decolonization. Reclaiming the messages and embodied practices left to us by our ancestors can provide an empowering collective approach to pregnancy, birth, and afterbirth, and can facilitate a “decolonized pathway” (Simpson 28) into and through the world for our children and for generations to come

Paradoxical mobilities: sharemilking with Te Raparahi Lands Trust (Wāotū)

Mobilities are important for capturing some of the combined movements of people, animals and objects in all of their complex relational dynamics. Sharemilking involves a cascade of mobilities: from the modest journies of the everyday to the upheaval of complete farm moves. Here we examine how sharemilkers are enabled and constrained in different ways by being mobile and landless, but also included are hopeful geographies. The sharemilker's mobile relationship to land, rather than ownership of it, works well with indigenous ideas of kaitiakitanga (guardianship) that is a central feature of multiply owned Māori land trust (Te Raparahi). Combining sharemilker mobility with te Raparahi, and importantly Ngāti Hūri historical and contemporary connections to Te Wāotū in South Waikato, Aotearoa New Zealand, reveals paradoxical mobilities of place

Strategies for teaching gender in geography

One hour session presented in Auckland at the Women Gender Geography Research Network (WGGRN) Symposium. We discuss: What does geography add to gender? Affect in the classroom. Personal politics; the personal is political

Here to stay: Reshaping the regions through mana Māori

Situated 65 kilometres south-east of Hamilton, Putāruru (population 3747 in the 2013 Census) is typical of the many farming service towns scattered across rural Aotearoa New Zealand. Bakeries, op shops, a sports bar and a farm equipment supplier occupy the main street. Unlike nearby Tirau, which transformed from a one-stop shop into a vibrant boutique village in the late 1990s, Putāruru township remains largely indistinguishable from other rural centres. There are few clues to the substantial farming-based and water-generated wealth that lies beyond the town

Iwi, institutes, societies & community led initiatives

With the rapid evolution, innovation and incredible growth of ICT, the avenues to exchange, access, manage, create, disseminate, display and research Indigenous data and Mātauranga Māori have increased at astounding rates. This generation, often referred to as ‘digital natives', ‘homo zappiëns’, ‘Net generation’, ‘millennials’, ‘i-generation’ (see, for example Akçayır, Dündar, & Akçayır, 2016; Kirschner & De Bruyckere, 2017; Prensky, 2001; Yong & Gates, 2014), have been raised, immersed and exposed to a myriad of digital technologies, video games, computers, digital music players and cellular phones during their brief lifetimes. Technologies have dramatically transformed how each generation access, communicate, share knowledge, distribute and view information. Social networks like Facebook, YouTube, Instagram, Twitter, Reddit, Pinterest, Tumblr and social networking apps such as Messenger, WhatsApp, WeChat, QQ Chat, QZone, Viber, LINE, and Snapchat, with billons of active users per month, are as familiar to this generation as was the radio, television and landline telephones to the Baby Boomers who grew up with pre-cellphone mobile technology

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Adding 6 months of androgen deprivation therapy to postoperative radiotherapy for prostate cancer: a comparison of short-course versus no androgen deprivation therapy in the RADICALS-HD randomised controlled trial

Background Previous evidence indicates that adjuvant, short-course androgen deprivation therapy (ADT) improves metastasis-free survival when given with primary radiotherapy for intermediate-risk and high-risk localised prostate cancer. However, the value of ADT with postoperative radiotherapy after radical prostatectomy is unclear. Methods RADICALS-HD was an international randomised controlled trial to test the efficacy of ADT used in combination with postoperative radiotherapy for prostate cancer. Key eligibility criteria were indication for radiotherapy after radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to radiotherapy alone (no ADT) or radiotherapy with 6 months of ADT (short-course ADT), using monthly subcutaneous gonadotropin-releasing hormone analogue injections, daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as distant metastasis arising from prostate cancer or death from any cause. Standard survival analysis methods were used, accounting for randomisation stratification factors. The trial had 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 80% to 86% (hazard ratio [HR] 0·67). Analyses followed the intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov, NCT00541047. Findings Between Nov 22, 2007, and June 29, 2015, 1480 patients (median age 66 years [IQR 61–69]) were randomly assigned to receive no ADT (n=737) or short-course ADT (n=743) in addition to postoperative radiotherapy at 121 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 9·0 years (IQR 7·1–10·1), metastasis-free survival events were reported for 268 participants (142 in the no ADT group and 126 in the short-course ADT group; HR 0·886 [95% CI 0·688–1·140], p=0·35). 10-year metastasis-free survival was 79·2% (95% CI 75·4–82·5) in the no ADT group and 80·4% (76·6–83·6) in the short-course ADT group. Toxicity of grade 3 or higher was reported for 121 (17%) of 737 participants in the no ADT group and 100 (14%) of 743 in the short-course ADT group (p=0·15), with no treatment-related deaths. Interpretation Metastatic disease is uncommon following postoperative bed radiotherapy after radical prostatectomy. Adding 6 months of ADT to this radiotherapy did not improve metastasis-free survival compared with no ADT. These findings do not support the use of short-course ADT with postoperative radiotherapy in this patient population

Duration of androgen deprivation therapy with postoperative radiotherapy for prostate cancer: a comparison of long-course versus short-course androgen deprivation therapy in the RADICALS-HD randomised trial

Background Previous evidence supports androgen deprivation therapy (ADT) with primary radiotherapy as initial treatment for intermediate-risk and high-risk localised prostate cancer. However, the use and optimal duration of ADT with postoperative radiotherapy after radical prostatectomy remains uncertain. Methods RADICALS-HD was a randomised controlled trial of ADT duration within the RADICALS protocol. Here, we report on the comparison of short-course versus long-course ADT. Key eligibility criteria were indication for radiotherapy after previous radical prostatectomy for prostate cancer, prostate-specific antigen less than 5 ng/mL, absence of metastatic disease, and written consent. Participants were randomly assigned (1:1) to add 6 months of ADT (short-course ADT) or 24 months of ADT (long-course ADT) to radiotherapy, using subcutaneous gonadotrophin-releasing hormone analogue (monthly in the short-course ADT group and 3-monthly in the long-course ADT group), daily oral bicalutamide monotherapy 150 mg, or monthly subcutaneous degarelix. Randomisation was done centrally through minimisation with a random element, stratified by Gleason score, positive margins, radiotherapy timing, planned radiotherapy schedule, and planned type of ADT, in a computerised system. The allocated treatment was not masked. The primary outcome measure was metastasis-free survival, defined as metastasis arising from prostate cancer or death from any cause. The comparison had more than 80% power with two-sided α of 5% to detect an absolute increase in 10-year metastasis-free survival from 75% to 81% (hazard ratio [HR] 0·72). Standard time-to-event analyses were used. Analyses followed intention-to-treat principle. The trial is registered with the ISRCTN registry, ISRCTN40814031, and ClinicalTrials.gov , NCT00541047 . Findings Between Jan 30, 2008, and July 7, 2015, 1523 patients (median age 65 years, IQR 60–69) were randomly assigned to receive short-course ADT (n=761) or long-course ADT (n=762) in addition to postoperative radiotherapy at 138 centres in Canada, Denmark, Ireland, and the UK. With a median follow-up of 8·9 years (7·0–10·0), 313 metastasis-free survival events were reported overall (174 in the short-course ADT group and 139 in the long-course ADT group; HR 0·773 [95% CI 0·612–0·975]; p=0·029). 10-year metastasis-free survival was 71·9% (95% CI 67·6–75·7) in the short-course ADT group and 78·1% (74·2–81·5) in the long-course ADT group. Toxicity of grade 3 or higher was reported for 105 (14%) of 753 participants in the short-course ADT group and 142 (19%) of 757 participants in the long-course ADT group (p=0·025), with no treatment-related deaths. Interpretation Compared with adding 6 months of ADT, adding 24 months of ADT improved metastasis-free survival in people receiving postoperative radiotherapy. For individuals who can accept the additional duration of adverse effects, long-course ADT should be offered with postoperative radiotherapy. Funding Cancer Research UK, UK Research and Innovation (formerly Medical Research Council), and Canadian Cancer Society