Topic 5: Whānau education and involvement

Justification

There is clear qualitative evidence supporting the inclusion of whānau as essential team members. Communication by healthcare professionals has also been highlighted as champions for whānau. The foundations of Te Ao Māori values provide the fundamental pou (pillar) for care.

Subgroup considerations

Subgroup considerations include diversity in iwi and hapū affiliations, levels of connection to te ao Māori, whānau structures and decision-making roles, geographic distance from rohe, language preferences, socioeconomic barriers, and prior experiences of healthcare and racism. Culturally safe care requires responsiveness to these differences as defined by whānau Māori themselves.

Implementation considerations

Implementation will require staff training in cultural safety and relationship-centred communication, support from Māori health teams, and processes that enable whakawhanaungatanga. Services should also ensure the environment supports extended whānau involvement and consistent, clear information-sharing. Recruiting more Māori staff would benefit the overall cultural care of the whanau Māori. Implementation should include a designated cultural support role, such as a Māori health worker, kaiāwhina or Whānau Ora navigator, to support culturally safe communication and care planning as determined by whānau Māori, rather than relying on individual staff availability or discretion.

Monitoring and evaluation

Monitoring should focus on whānau experience measures, cultural safety audits, and regular equity-focused quality-improvement reviews. Feedback from whānau Māori should guide iterative improvements, using structured methods such as PDSA cycles.

Research priorities

• Future research should evaluate specific communication models, test scalable culturally informed interventions, and measure outcomes identified as important by whānau Māori.
• Studies examining system changes that sustainably support culturally safe neonatal care are also needed.
  

Justification

The limited available evidence shows that Pacific families place the highest value on relationship-centred care, where trust, time, respect and spirituality are honoured, and where extended family are included in decision-making. Without culturally grounded engagement that aligns with these values, communication is less effective and can conflict with traditional practices, reducing the acceptability and uptake of nutrition care advice.

Subgroup considerations

Pacific communities are diverse; communication preferences differ across Polynesia, Melanesia and Micronesian countries. The extended family, including grandparents and aunties, often play central roles and may require information in Pacific languages. Considerations also differ for extremely preterm, VLBW, and moderate to late preterm infants due to different care journeys and stressors.

Implementation considerations

Implementation will require Pacific peoples’ expertise, cultural leadership, and workforce development, using the principals of Yavu, culturally safe spaces for prayer and family presence, and translated or visual health information. Services will need support to shift from transactional information-giving to relationship-centred, family-inclusive communication.

Monitoring and evaluation

Evaluation should prioritise families’ experience, culturally safe structured methods and include safety feedback, and the effectiveness of communication processes for Pacific families. Monitoring should assess focus on Pacific families’ experiences and frequent equity-focused quality-improvement audits (whether the extended family feel informed, involved, and culturally supported) and whether changes reduce disparities in neonatal outcomes and experience.

Research priorities

There is an urgent need for research directly involving Pacific families of preterm infants, using Pacific research methodologies. Priorities include identifying preferred communication models in NICU/SCBU, evaluating culturally grounded interventions, supporting common values between Pacific Peoples whilst understanding subgroup differences across Pacific Peoples nations, and assessing impacts on feeding, engagement, and clinical outcomes.

Justification

There are no direct intervention studies assessing the effects of integrating tikanga-based kai practices in NICU. The existing qualitative evidence consistently indicates that kai is integral to whānau wellbeing, connection, manaakitanga and breastfeeding success, and that hunger and lack of culturally appropriate food negatively impact whānau Māori. However, the absence of measurable neonatal or maternal clinical outcomes means certainty of effect remains very low.

Subgroup considerations

Extremely preterm, VLBW and MLPT pēpi Māori may experience different lengths of stay, levels of parental stress, and reliance on whānau support; therefore, the importance of tikanga-based kai practices may be even greater in families spending long periods in NICU. Rural whānau and those cared for far from home may particularly benefit due to food insecurity and reduced access to extended whānau support. It is important that whanau Māori are offered the option to have traditional tikanga like karakia involved in the process. Some whanau Māori will not take up the option, and some may be offended by health practitioners assuming they know what's best in this regard for whanau Māori.

Implementation considerations

Implementing tikanga-based kai practices requires careful co-design with whānau Māori, consideration of space for communal food preparation and eating, culturally appropriate kai options and reviewing visiting policies to support extended whānau involvement. It is critical more health providers have staff with bi cultural skills.

Monitoring and evaluation

If implemented, services should monitor whānau satisfaction, cultural safety indicators, breastfeeding outcomes and whānau stress. Measuring uptake and acceptability among staff and whānau Māori will be essential to guide refinement.

Research priorities

• High-quality Kaupapa Māori research is needed to evaluate the clinical and whānau outcomes of tikanga-based kai practices in NICU, including impacts on breastfeeding and other outcomes.
• Research should also explore cost implications, equity gains and be co-led by Māori.
  

Justification

Small positive effect, but no harm. While the overall certainty of evidence is very low, the potential benefits of early education are in important outcomes, such as increased breastfeeding rates, improved maternal engagement, lactation and provision of breastmilk. The effects are uncertain due to imprecision and high heterogeneity, but the direction of effect generally favours education, and harms are minimal or not demonstrated. Given the low cost, likely acceptability and existing practice in some units, early education can be considered a low-risk, potentially high-benefit intervention. The equity implications are substantial, particularly for pēpi Māori, Pacific peoples and underrepresented groups who face systemic barriers to breastfeeding.

Subgroup considerations

No specific data were available for pēpi Māori, but disparities in outcomes support prioritising education for Māori. Some studies included moderate to late preterm and low birthweight infants, which may limit generalisability to extremely preterm infants. The effect of education may differ depending on gestational age, timing and content of education and availability of breast pumps and lactation support.

Implementation considerations

Education should be timely, structured and culturally responsive, ideally beginning antenatally or shortly after birth. Implementation could be variable depending on staffing, parental presence, and resources (e.g., breast pumps, space, interpreters). Content should include the importance of early and frequent expression, use of nutritional supplements, and fortification. Services should prioritise Māori and ensure whānau-centred care and include equity-focus. Te Ao Māori input into the education would be needed to ensure it had the most benefit. May require staff education or protocols to standardise messaging and support.

Monitoring and evaluation

Track exclusive breastfeeding at discharge. Monitor early expression practices, milk volume and maternal confidence/knowledge (e.g. use of Breastfeeding Self-Efficacy Scale). Collect feedback from parents on experience, barriers and support received. Consider auditing equity of access and outcomes by ethnicity and gestation.

Research priorities

High-quality RCTs that examine early education packages stratified by gestational age and with the inclusion of whānau Māori and Pacific peoples. Studies on delivery methods (in-person, digital, peer-led) and culturally specific approaches. Cost-effectiveness evaluation. Whānau Māori perspectives on what is helpful is essential.

Justification

The evidence from qualitative and observational studies demonstrates consistent benefits for whānau when additional education is provided. These include improved satisfaction, greater confidence in caregiving, reduced stress and depression, and enhanced decision-making. While effects on clinical outcomes (e.g. breastfeeding at discharge, infant growth) are uncertain or low certainty, the intervention aligns with principles of whānau-centred care and is likely acceptable. Importantly, additional education methods must be culturally appropriate, accessible, and delivered in ways that support relational, inclusive, and meaningful communication. Given the variability in resource availability and delivery methods and the moderate-to-low certainty of some outcome data, a conditional recommendation is appropriate.

Subgroup considerations

Whānau Māori benefit when education is provided in ways that honour tikanga Māori, promote kanohi ki te kanohi (face to face) interaction, and support whānau empowerment and tino rangatiratanga. Pacific families value collective, visual, and oral methods of learning. Involving the wider family in education and tailoring content to their cultural needs increases its impact. Families from rural, migrant, or low-resource backgrounds may need flexible delivery modes (e.g. online, interpreters, translated materials) to ensure equitable access.

Implementation considerations

Education should combine written, face-to-face, and digital tools. Staff time and training may be needed to deliver content appropriately and culturally safely. Co-design with whānau Māori and Pacific providers is essential to ensure relevance and acceptability.

Monitoring and evaluation

Collect whānau feedback on education methods and satisfaction with communication. Monitor indicators of parental wellbeing, confidence, and readiness for discharge and type of feeding at discharge. Audit the consistency of education delivery across units and assess access by ethnicity, language, and socioeconomic status. Monitor feeding and clinical outcomes.

Justification

The available evidence is of low to very low certainty. While no clear clinical benefits were observed in outcomes such as mortality, NEC, breastfeeding at discharge, or growth, one RCT reported reduced feeding intolerance and improved parental well-being and confidence. These effects, though modest, align with broader goals of family-integrated care. Importantly, encouraging parental participation may contribute to improved equity, cultural safety, and bonding, especially when implemented with appropriate support.

Subgroup considerations

For whānau Māori, engagement in feeding-related tasks may promote tino rangatiratanga, support breastfeeding intentions, and restore traditional caregiving roles. However, historical mistrust and systemic barriers must be addressed through culturally safe, inclusive practices. Pacific families may face barriers such as time, language and health literacy. Tailored, respectful education and support is essential to enable meaningful participation. Families from rural, migrant or low-resource settings may require flexible visiting policies, interpreters and additional support to ensure inclusion.

Implementation considerations

Requires staff training to coach and support parents safely and confidently, especially for technical tasks like tube feeds or fortifier measurement. Needs clear protocols to manage risk and standardise parental involvement, alongside documentation of consent and competency. Time and workload implications should be balanced against potential gains in parental confidence, infant wellbeing and care satisfaction.

Monitoring and evaluation

Monitor uptake and consistency of parent involvement in feeding-related tasks across units. Collect qualitative feedback from parents and staff about barriers, facilitators and acceptability.

Research priorities

Studies assessing the impact of parent involvement in tube feeding and supplement preparation on:

• Breastfeeding initiation and continuation, parental stress, confidence, and bonding.
• Māori- and Pacific-led qualitative research on parental experiences and culturally safe implementation strategies.
• Cost-benefit and feasibility studies, particularly in resource-limited settings.