ABSTRACT Introduction Despite growing awareness of increasing rates of youth suicide and self-harm in New Zealand, there is still little known about self-harm among rural youth. Aim This study compared: (1) rates of youth self-harm presentations between a rural emergency department (ED) and nationally available rates; and (2) local and national youth suicide rates over the decade from January 2008 to December 2017. Methods Data were requested on all presentations to Ashburton Hospital ED coded for ‘self-harm’ for patients aged 15–24 years. Comparative data were obtained from the coroner, Ministry of Health and the 2013 census. Analyses were conducted of the effects of age, time, repetition, method, ethnicity and contact with mental health services on corresponding suicide rates. Results Self-harm rates in Ashburton rose in the post-earthquake period (2013–17). During the peri-earthquake period (2008–12), non-Māori rates of self-harm were higher than for Māori (527 vs 116 per 100 000 youth respectively), reflecting the national trend. In the post-earthquake period, although non-Māori rates of self-harm stayed stable (595 per 100 000), there was a significant increase in Māori rates of self-harm to 1106 per 100 000 (Chi-squared = 14.0, P < 0.001). Youth living within the Ashburton township showed higher rates than youth living more rurally. Discussion Youth self-harm behaviours, especially self-poisoning, have increased since the Canterbury earthquakes in the Ashburton rural community. Of most concern was the almost ninefold increase in Māori self-harm presentations in recent years, along with the increasing prevalence among teenagers and females. Possible explanations and further exploratory investigation strategies are discussed.