Health

Indicators
Introduction
1. Life expectancy
2. Child morbidity
3. Child mortality
4. Child abuse
5. Young adults
6. Adult morbidity
7. Adult mortality
8. Discussion
Data sources
References

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Indicators

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Introduction

'Health is one of the most extraordinarily sensitive indicators of the social costs of inequality.' (Kawachi et al. (1999), p.1.) However, there is no one simple way to measure health status. A number of different approaches can be taken, limited by what information is available and useful. This part of the report looks at the health of Māori women in New Zealand by analysing some of the major categories of information about deaths, use of hospital services, and smoking.

Using the indicators listed above, the health situation of Māori females is compared to Māori males, non-Māori females and non-Māori males. For some indicators, the numbers of people involved was quite small. For example, the number of Māori girls who died from meningococcal disease, the number of deaths from suicide or the number of young Māori women who die in road traffic accidents.

Where the numbers involved are less than 30, the data has not been converted to rates as rates will not be meaningful. (The Ministry of Health advises that it is better to use actual numbers rather than rates where the underlying numbers are very small.) Indicators with small underlying numbers should be treated with caution.

Death rates, and in particular ages at death and causes of death, are key indicators of the health of the population. The number of hospital admissions and the reason for these contacts are used as a proxy measure of the health and ill health of a population. It is easier to count such health care 'events', rather than other measures such as self reported illness. (Ministry of Health (1999a).) Hospital admissions are influenced by factors such as availability of resources and admission and discharge policies.

There is a continuing need to monitor statistics concerned with mortality and morbidity among Māori women, in order to improve understanding of health priorities. Te Puni Kōkiri and the Ministry of Women's Affairs (1999) have examined the health and well-being of Māori women. The Ministry of Women's Affairs has considered the needs and aspirations of Māori women throughout its Women's Health Strategy (currently being developed). Several agencies have also been involved in examining the impact of social and economic determinants on health and have included Māori women in comparative analyses.

The disparities between the health status of Māori and non-Māori New Zealanders have been well documented by other analyses (e.g., Te Puni Kōkiri, 2000a; Howden-Chapman & Tobias, 2000). Some of these analyses contain data broken down by both ethnicity and sex. Analyses by ethnicity have to take into account both numerator and denominator issues within the classification of ethnicity, for example, the change of the definition of Māori in the 1996 census, the misclassification of Māori by coroners, and the undercounting of Māori in hospital data. (Pōmare et al. (1995).) A further complication relates to changes in the classification and coding of ethnicity in health data which took place around 1996. (Ministry of Health (1999a).) As a result it has generally only been possible to use one period of data in this chapter. Caution should be exercised when interpreting data from one period as results may reflect atypical situations.

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Deprivation and health
Disparities in the health status of different groups are now often examined using NZDep96, an area-based index of deprivation which has been used to indicate socio-economic status. (Salmond, Crampton & Sutton (1998), in Ministry of Health (1999a). Note that the validity of using a spatially based index of deprivation to indicate the socio-economic status of individuals is still under debate. However, Clare Salmond has compared the spatially based index with an individually based version as a predicator of smoking in the 1996 Census. There was a high level of correlation between the spatially based and individually based versions of the index.) Use of this index has clearly shown that Māori are over-represented in the most deprived areas of the country and under-represented in the least deprived. (Reid, Robson & Jones (in press).) Within this chapter the health status of Māori women is considered across different age groups for a variety of indicators of health status. Where possible, time series and NZDep96 results are included.

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Māori views of health
It is acknowledged that the chapter focuses mainly on morbidity and mortality. There is also a need to talk about the health of Māori women more broadly and to focus on positive aspects. While knowledge about disparities may motivate the initiation and financial support of interventions, knowledge about how best to intervene is often held within communities and discussions at hui, as well as within research findings.

One Māori view of health encompasses tinana (the physical element), hinengaro (the mental state), wairua (the spirit) and whānau (the immediate and wider family) within the health pounamu. (Murchie (1984).) Also known as the Whare Tapa Wha, (Durie (1994).) (Tamariki Ora (1993), p.24.) these aspects occur in the context of Te Whenua (land providing a sense of identity and belonging), Te Reo (the language of communication), Te Ao Turoa (environment) and Whanaungatanga (extended family).

The 1984 Māori Women's Welfare League research report, Rapuora: Health and Māori women (Murchie, 1984), notes that: "it is not possible to study either the physical health of the Rapuora women or their social and economic well-being in isolation from the whānau, the network of people who are linked by blood, and the wider community within which the family group functions." (Murchie (1984), p.67.)

Other models and discussions of Māori health have added other dimensions including, for example, economic security, educational achievement, a home free from violence, and political representation. (Public Health Group (1997); Pōmare et al. (1995); Walker and Mead (1992).) Māori women's health is therefore more than the absence of disease; there is a focus on well-being.

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1. Life expectancy

1.1 Life expectancy at birth
Position of Māori girls: In 1995-97, life expectancy at birth for Māori girls was 71.6 years.

Table D1. Years of life expectancy at birth, 1960-1997

Life expectancy at birth is derived from official life tables. These life tables are produced every 5 years and are based on a 3-year period centred around a Census year.
Source: Statistics New Zealand.

Table D1 shows the average length of life that Māori and non-Māori females and males can expect at birth. The relatively poor health of Māori women is summarised by the fact that while their life expectancy at birth has improved by 10 years since 1960-62, to 71.6 years, the largest increase for any group, it is still 9 years shorter than non-Māori women's life expectancy.

The years 1995-97 showed a decrease in life expectancy for both Māori women and Māori men, compared with 1990-92. Māori males born in 1995-97 could expect to live only 67.2 years. By contrast, the life expectancy of non-Māori women and men has continued to improve.

As Table D1 shows, Māori women have a longer life expectancy than Māori men. Part of women's advantage in relation to life expectancy is biological in origin. Endogenous hormones seem to protect women from ischemic heart disease, the major cause of mortality and morbidity in males and in postmenopausal females.

Death statistics chart the quantity of life that a population enjoys, but they say nothing about quality of life or experience of ill health. Many significant causes of disease and disability are rarely a direct cause of death. Māori women are more likely than Māori men or non-Māori women and men to suffer from osteoporosis, diabetes, hypertension, arthritis and most immune disorders. Biological factors are likely to play some part in this as well. (Ministry of Health (2000a); Lynch (1997).)

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Low birth weight
Low birth weight is known to be strongly associated with perinatal and infant mortality (MoH, 1998). Low birthweight infants are over 20 times more likely to die in the first year of life, and are more susceptible to serious illness in infancy and later life. Low birth weight is one of the major risk factors for Sudden Infant Death Syndrome (SIDS). Table D2 shows that in 1997, the rate of low birthweight births was higher for Māori than for Pacific or Other.

Table D2. Live births by birthweight, ethnicity* and year, 1997

Live births by birthweight is data not available by sex.
Other includes Pakeha/European.
Source: NZ Health Information Service

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Survival by age
Ethnic differentials in survival chances can also be illustrated by comparing the probabilities of surviving from one age to another. Table D3 shows that at all age levels, except 85 years, the life expectancy of Māori women is less than the life expectancy of non-Māori women and men (Table D2). Only the life expectancy of Māori men and Pacific men is shorter. At age 1, a Māori female infant has a 98.7% chance of surviving to age 25, compared with 99.2% for a European/other infant. A Māori male infant has a 97.6% percent chance of reaching age 25, compared with 98.7% for a European/Other male infant. (Lewis (2001), p.8.)

Table D3. Years of life expectancy at selected ages, 1995-97

Note that non-Maori in these columns includes Pacific.
Source: Ministry of Health 1999b, in Lewis, 2001.

Life expectancy is strongly related to socio-economic status. However, Ministry of Health research has also shown that ethnicity has an additional impact. As Figure D1 shows, for 1995-97, the difference in life expectancy between Māori women and European women (i.e. excluding Pacific women) was greatest among the most disadvantaged (i.e. those in Deprivation Group 10, the tenth and worst decile of deprivation, as measured by NZDep96). For these two groups the disparity lengthened to 10.1 years. (Howden-Chapman & Tobias (2000); Reid, Robson & Jones (in press).)

Figure D1. Male and female life expectancy at birth, by level of deprivation, 1995-1997

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2. Child morbidity

The United Nations Convention on the Rights of the Child states that all children (up to the age of 18 years) have the right to survival, protection and development. Children and young people are largely dependent on others for care, protection and access to services. Their rapid development brings rapidly changing needs and health issues.

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2.1 Hospitalisation for meningococcal disease
Position of Māori girls: In 1999, the hospitalisation rate for Māori girls aged under 15 for meningococcal disease was 65.1 per 100,000 population.

Table D4. Rates of hospitalisation per 100,000 for meningococcal disease, aged under 15, 1996-99

Source: Environmental Science and Research Ltd.

As Table D4 shows, from 1996 to 1999, admissions to hospital for meningococcal disease were between 22 and 38 percentage points higher for Māori girls than for non-Māori girls. The disparity between Māori and non-Māori boys was more variable – between 15 and 53 percentage points. The rate for Māori girls increased from 1996 to 1999, whereas the rate for non-Māori girls reduced, the rate for Māori boys fluctuated markedly, and the rate for non-Māori boys fluctuated less markedly.

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Hospitalisation for acute respiratory infections and asthma
As Table D5 shows, rates of admission of Māori girls (under 15 years of age) to hospital were particularly high for acute respiratory infections and for asthma. These rates were higher than for non-Māori girls, but considerably lower than for Māori boys in the same age group.

Table D5. Numbers and rates per 100,000 of hospitalisation for acute respiratory infections/asthma, aged under 15, 1997/98

Source: NZ Health Information Service

Māori children are heavily over-represented in hospitalisation rates for preventable childhood conditions such as meningococcal disease, acute respiratory infections and asthma. These conditions have a direct link to causative factors of overcrowding and poor housing.

Some hospitalisations could be avoided with early intervention and improved access to primary care. Smoking is an important risk factor increasing Māori children's susceptibility to respiratory infections and asthma. The significance of respiratory disease differs across the life span. Poorly managed respiratory problems in childhood lead to a high incidence of chronic pulmonary disease and asthma in Māori women as adults.

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2.2 Hospitalisation for all causes
Position of Māori girls: In 1997/98, the all-cause hospitalisation rate for Māori girls aged under 15 was 1,458 per 10,000 population.

Surprisingly, despite the hospitalisation rates given above, the 1997/98 rates of hospitalisation for all causes for Māori girls and boys under 15 years of age were lower than the comparable rates for non-Māori (Table D6). Provisional data for the 1998/99 year shows a similar pattern. The reasons for this counter-intuitive result are not clear but may be related to the method of classifying ethnicity used by hospitals which may have led to under-reporting of Māori hospitalisations. Further research would be required to determine the exact cause. Given the uncertainty attached to the accuracy of this data these hospitalisation rates should be treated with caution.

Table D6. Numbers and rates per 10,000 of hospitalisation for all causes, aged under 15, 1997/98

Source: NZ Health Information Service

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3. Child mortality

3.1 Mortality from meningococcal infection

Position of Māori girls: In 1999, 4 Māori girls aged under 15 died from meningococcal infection.

As Table D7 shows, in 1999, 4 Maori girls, 4 Maori boys, 3 non-Maori girls and 2 non-Maori boys died from meningococcal infection. It should be noted that very small numbers of children under 15 die from meningococcal infection. Nevertheless, these figures indicate a serious health risk, particularly for Māori children.

Table D7. Numbers of deaths from meingococcal infection, aged under 15, 1996-1999

Source: Environmental Science and Research Ltd

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3.2 Mortality from all causes

Position of Māori girls: In 1997, the death rate for Māori girls aged under 15 from all causes was 10.4 per 10,000.

As Table D8 shows, there were striking ethnic differences in death rates for children under 15 in 1997. The overall mortality rate for Māori girls (10.4 per 10,000) was lower than that for Māori boys (13.9 per 10,000), but over twice as high as the rate for non-Māori girls (4.9 per 10,000) in the same age group. The disparity between young Māori and non-Māori boys (13.9 per 10,000 compared with 5.8 per 10,000) was even larger.

Table D8. Number and rates of mortality per 10,000 all causes, under 15 years of age, 1997

Source: NZ Health Information Service. This is the only year for which data was available from NZHIS.

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4. Child abuse

While abuse of children has assumed a new prominence in the public health arena, information about this area is limited. The shortage of good information means that little is known about risk factors. Injuries from abuse can have long term health consequences for children and significantly affect their emotional well-being. It is also possible that many of the physical injuries sustained as a result of childhood abuse may remain untreated.

There are various sources of data which provide information on child abuse. The rate of hospitalisation and of deaths from homicide and injury purposely inflicted by others have been used as the indicators here. The Ministry of Health regards these as useful sets of national statistics on child abuse.

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4.1 Hospitalisation and mortality due to non-accidental injury by others

Position of Māori girls: In 1997, for Māori girls aged under 15, the hospitalisation rate for homicide and injury deliberately inflicted by others was 40.7 per 100,000 population.

Table D9. Numbers and rates per 100,000 of homicide and injury purposefully inflicted by other persons on children aged under 15, 1997

Source: NZ Health Information Service

Table D9 shows that in 1997, Māori girls aged under 15 were more than four times as likely as non-Māori girls to be admitted to hospital for homicide and injury purposely inflicted by other persons. The rate for Māori boys (43.3 per 100,000) was a little higher than the rate for Māori girls (40.7), and one and a half times higher than the rate for non-Māori boys (27.4). Non-Māori boys were three times as likely as non-Māori girls (9.0) to be admitted to hospital for this cause.

In terms of deaths, in 1997, the numbers are too small to be able to make meaningful comparisons.

Statistics collected by the National Council of Independent Women's Refuges (NCIWR) point to the over-representation of Māori women and children among those using Women's Refuges. In 1999, 3,085 Māori women and 4,851 Māori children (compared with 3,899 non-Māori women and 4,636 non-Māori children) used NCIWR refuge services. (See Justice for more information on refuge use by Māori women and children.)

In 1998/99 year CYPF substantiated some form or multiple forms of abuse and neglect for 2,808 children aged 0-6 and 3,392 young people aged 7-16 years. Approximately 46% of children and young people with substantiated findings of abuse and neglect are Māori, 34% European, and 11% Pacific children. The rate for substantiated notifications to CYFS of abuse and neglect for 1998/99 was 1.2% of Māori children aged 16 and under. This was three times the non-Māori rate of 0.4% (Table D10).

Table D10. Numbers and rates per 100 of substantiated notifications to CYFS of abuse and neglect of those aged 16 and under, 1998/99

Source: Strengthening Families: Report on Cross Sectoral Outcome Measures and Targets 1999, p.24. Data by sex is not readily available.

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5. Young adults

5.1 Suicide and self-inflicted injury
Table D11. Numbers and rates per 100,000 of hospitalisation and number of deaths as a result of suicide and self-inflicted injury aged 15-19, 1997

Source: NZ Health Information Service

New Zealand has among the highest rates in the OECD for suicide and attempted suicide, and it is the youth of the country who are over-represented in these statistics. (Lewis (2001).) 20 Suicide is a cause of premature mortality and significant years of life lost. It is also the cause of ongoing emotional and psychological distress for family and friends. Self-inflicted injuries can result in long term health problems and ongoing disability.

The rate of hospitalisation for suicide and self-inflicted injury during 1997/98 was highest for young non-Māori women, followed by young Māori women (Table D11). The mortality figures are too small to be able to make meaningful comparisons.

The female excess in hospitalisations for self-harm 'reflects their much lower rate of completed suicide compared to males'. (Lewis (2001).) However, the data suggest that young Māori women's mortality rate is rising as they increasingly choose more 'successful' methods. (Pōmare et al. (1995).)

Statistics probably under-estimate the incidence of attempted suicide for women, as they may harm themselves without ever being admitted to hospital. Very few studies specifically focus on suicide risk factors for Māori women or explore whether the risk factors Māori women face differ from those facing Māori men. This may be partly because investigators tend to view suicide as mainly a 'male problem'. Not surprisingly, studies of risk factors for self-inflicted injury have found that being female itself constitutes a risk. (Fanslow & Norton (1994).)

Studies from many parts of the world show that women are more likely than men to report symptoms of mental illness and are more likely to receive treatment for conditions such as the less severe forms of anxiety and depression. Though regarded as less severe, these conditions can be associated with significant morbidity. (Noelen-Hoeskema (1987).) The higher female rates for these mental illnesses are attributed to women's adverse social circumstances, including poverty, single parenthood, educational and work inequalities. (For example, Lennon (1995); Romans-Clarkson (1991).) Women are more likely to hold jobs with low level of control over work, poor job security and low wages. These characteristics explain, at least in part, women's higher risk of psychological disorder, especially depression. (Lennon (1995).)

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5.2 Mortality from motor vehicle traffic accidents
Table D12. Position of young Māori women: In 1997, 7 Maori women aged 15-19 died in motor vehicle traffic accidents

Source: NZ Health Information Service

Young non-Māori men accounted for 48.1% of all deaths from motor vehicle traffic accidents, but they comprised 40.9% of the 15-19 year population. In comparison, Māori men accounted for 27.2% of these deaths and 10.4% of the population, Māori women accounted for 8.6% of deaths from motor vehicle traffic accidents and 10.2% of the population, and non-Māori women accounted for 16.0% of these deaths and 38.5% of the population. Relative to their population proportions, young Māori men and women are more likely to die from road traffic accidents than their non-Māori counterparts. This disparity remains in spite of considerable decreases in road traffic mortality from 1981 to 1997. (Te Puni Kōkiri (2000a).) 27

Motor vehicle accidents are a major cause of premature death for young Māori. They also result in significant disabling injuries that can substantially affect quality of life and ability to participate fully in society.

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5.3 Fertility rates
Position of young Māori women: In 2000, the fertility rate for young Māori women aged 11-17 was 1.56 per 100 population.

Table D13. Fertility rates* per 100 females aged 11-17, 1990, 1995, 2000

* Fertility rates is the number of registered births divided by the estimated mean population
Source: Statistics NZ

Fertility is one of the key influences on population growth, together with death and migration (Pōmare et al., 1995). The fertility rate for all Māori women declined steeply between 1962 and 1983, from 6.2 to 2.2 births per woman, and is now close to the fertility rate of non-Māori women. (A change in the method of recording ethnicity on birth registration forms from September 1995 is likely to have resulted in a more accurate recording of Māori births, but means that historical information on births is not comparable with current data.)

However, as Table D13 shows, in 2000 the fertility rate for young Māori women aged 11-17 (1.56) was over four times as high as the rate for young non-Māori women (0.34). Fertility rates for all those aged 11-17 fell considerably between 1990 and 2000. For both groups the rate stayed much the same between 1990 and 1995, but by 2000 it had decreased, halving for non-Māori and falling by about a quarter for Māori.

Young women who are at risk of emotional, psychological, social, economic, and physical stresses are at greater risk of having an unplanned pregnancy. Many young Māori women feel powerless and vulnerable, have low self-esteem, and experience feelings of alienation. (Kirby & Coyle (1997).)

Māori teenagers who become pregnant are much less likely than other pregnant teenagers to have a termination. (Ministry of Health (2000b).) Young Māori mothers can find it difficult to continue to participate in school or complete qualifications. This can limit their future opportunities to enter into further education or employment. Early sexual activity and multiple sexual partners can also affect sexual health, increasing the risk of contracting a sexually transmitted infection and of developing cervical cancer at later ages.

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6. Adult morbidity

6.1 Hospitalisation
Position of Māori women: In 1997/8, Māori women aged 15 and over were hospitalised at a rate of 2,488.4 per 10,000 population.

Table D14. Numbers and rates per 10,000 of hospitalisation by selected cause, aged 15+, 1997/98

Source: NZ Health Information Service, age standardised rates.

As Table D14 shows, the overall hospitalisation rate for Māori women is the highest of all four rates, followed by non-Māori women, Māori men and non-Māori men.

Women have higher all-cause hospitalisation rates than men, but the sex difference almost disappears when admissions for normal pregnancy are excluded. However, the causes differ by gender; for example, males have higher rates for injuries and heart disease, and females have higher rates for reproductive conditions.

Pōmare et al. (1995) report that since 1970, hospital admission rates for Māori have been 1.4 to 2.3 times as high as non-Māori rates. Almost one-third of all hospitalisations (excluding maternity, mental illness and disability support) have been assessed as potentially avoidable. One-third of these avoidable hospitalisations could have been avoided through health promotion interventions. The other two-thirds could have been avoided through more effective primary health care. (Ministry of Health (1999a).)

Chronic obstructive respiratory disease is the major cause of hospitalisation for Māori women. This condition dramatically affects the quality of life and causes premature death. The single most important risk factor is smoking. Other risk factors are lower socio-economic status and respiratory illness in childhood.

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Deprivation and ethnicity

For both males and females, people from the most deprived levels of socio-economic status are approximately twice as likely to be admitted to hospital as their more advantaged counterparts. However, Figure D2 shows that Māori are in fact less likely to be hospitalised than their European counterparts when age and level of deprivation are taken into account. This is the case despite the higher need for hospital care implied by the fact that Māori have all-cause mortality rates almost twice those of non-Māori (at all ages and for both sex).

Figure D2. Hospitalisation by deprivation decile, ethnicity and sex, 1997

Source: Ministry of Health (1999b), in Lewis (2001)

Māori women's use of hospital services appears to be less than proportionate to their greater need for health care services. One reason may be that Māori women experience greater barriers to access to health services than non-Māori women. General Practitioners (GPs) usually refer patients for hospital treatment. Evidence suggests that Māori do not use GP services as often as their overall patterns of mortality and hospital use indicate is necessary (Davis et al. (1997).) . Supporting this conclusion, the 1996-7 New Zealand Health Survey identified significant ethnic differences in the reporting of unmet health needs.

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6.2 Cervical cancer registration

Position of Māori women: In 1996, the cervical cancer registration rate for Māori women was 28.8 per 100,000 population.

The 1996 cervical cancer registration rate for non-Māori women was 13.0 per 100,000, less than half the Māori rate of 28.8 per 100,000. This means that Māori women are more than twice as likely as non-Māori women to develop cervical cancer. Cervical cancer is largely a preventable disease, because screening can detect pre-invasive cancer before malignancies occur. (These rates are age standardised.)

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6.3 Breast cancer registration

Position of Māori women: In 1996, the breast cancer registration rate for Māori women was 11.6 per 10,000 population.

This was the same as the rate for non-Māori women, 11.6 per 10,000. Breast cancer is an important issue for Māori and non-Māori women, because of its negative impact not only on survival, but on lifestyle, self-image and quality of life. (These rates are age standardised.)

6.4 Diabetes diagnosis

Position of Māori women: In 1996, 9.4% of Māori women aged 15 and over had been diagnosed with diabetes mellitus.

Table D15. Diabetes diagnoses, aged 15+, 1996

Source: Ministry of Health

As Table D15 shows, Māori women are more likely than Māori men to be diagnosed with diabetes. This is the reverse of the situation for non-Māori women and men. In 1996 Māori women were almost four times as likely as non-Māori women to be diagnosed with diabetes. Hospitalisation per 10,000 for diabetes mellitus (see Table D14) is over three times as likely for Māori women (27.3) as for non-Māori women (7.3). However, Māori men have the highest hospitalisation rate for diabetes mellitus (35.7), over three times the rate for non-Māori men (9.8).

Diabetes is a risk factor for other diseases. Long-term diabetes leads to secondary problems such as kidney, eye, heart and peripheral vascular disease, and can result in long term disabilities such as loss of sight and mobility. In pregnancy, diabetes can affect both the child and the mother. It can result in the baby being larger than average, leading to birth complications, and has also been implicated in congenital malformations.

There are sex differences in managing diabetes due to hormonal factors. Women have to consider and manage the use of oral contraceptives and HRT carefully. Insulin can also affect fertility. In the long-term, diabetes may promote cardiovascular failure in women more than men. Studies

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6.5 Coronary artery surgery (including bypass and angioplasty)

Position of Māori women: In 1997/98, Māori women aged 15 and over had a coronary artery surgery rate of 15.3 per 100,000 population.

Table D16. Numbers and rates per 100,000 of coronary artery surgery, aged 15+, 1997/98

Source: NZ Health Information Service, age standardised rate

As Table D16 shows, Māori women had the lowest rate of coronary artery surgery in 1997-98, less than half the rate of their non-Māori counterparts. There was a similar but even larger difference between Māori and non-Māori men. Yet both Māori women and Māori men have a much higher rate of death from ischemic heart disease (see below) than their non-Māori counterparts.

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6.6 Smoking

Position of Māori women: In the 1996 Census, 47.4% of Māori women said they were regular cigarette smokers.

Table D17. Prevalence of smoking, aged 15+, 1996

Source: Statistics NZ, adapted from Table 16a in the 1996 Census reference report 'Ethnic Groups'

As Table D17 shows, Māori women are two and a half times as likely to smoke as European/Other women, and more likely to smoke than Māori men. Overall, 31% of all Māori deaths between 1989 and 1993 have been attributed to cigarette smoking. (Laugesen & Clements (1998).) As well as active smoking, exposure to second hand smoke has major implications for the health of infants and children as well as adults. In relation to reproductive health, stillbirth, low birth weight, intrauterine growth retardation and premature rupture of membranes can all result from smoking during pregnancy. Smoking increases the risk of glue ear, asthma and SIDS for children. In recent years, 46% of deaths due to SIDS among Māori infants were attributable to smoking, compared with 24% of deaths due to SIDS among Pacific infants and among other Pakeha/European and other ethnic groups. (Ministry of Health (1999a).)

Data on smoking by age group shows that between ages 20 and 39, over half of all Māori women smoke, compared with 22-28% of European women. Among adults aged 25-44, there is a clear pattern of regular smoking increasing as level of deprivation increases (Figure D3). This pattern is similar for Māori and non-Māori women and men. However, there is a large disparity between Māori and non-Māori at all levels of deprivation, particularly for women, in the percentage smoking regularly. This data is from the 1996 census, so both ethnicity and tobacco use are self-reported.

Figure D3. Regular smokers, 1996 Census, aged 25-44 years, by ethnicity and deprivation

Source: Reid, Robson & Jones (in press).

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7. Adult mortality

7.1 Mortality

Position of Māori women: In 1997, the age standardised mortality rate for Māori women aged 15 and over was 91.3 per 10,000 population.

Table D18. Numbers and rates per 10,000 of mortality aged 15+, 1997

Source: Ministry of Health, age standardised rates

In 1997, as Table D18 shows, the age standardised mortality rate for Māori females was almost twice as high as the rate for non-Māori females. A Māori male who was 45 years old in 1996: 'had a 69.1 percent chance of reaching 65 years compared with 86.8 percent for a European/other male. This compares with 76.4 percent and 91.7 percent for females respectively'. (Lewis (2001), p.8.)

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7.2 Mortality from heart disease, cervical cancer and lung cancer

Position of Māori women: In 1997, mortality rates for Māori women aged 15 and over were 187.0 per 100,000 of population for ischemic heart disease, 11.6 per 100,000 of population for cervical cancer, and 80.0 per 100,000 of population for lung cancer.

Table D19. Numbers and rates per 100,000 by selected causes of death, aged 15+, 1997

Source: NZ Health Information Service, age standardised rates.

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Ischemic heart disease
This is the leading cause of death for Māori and non-Māori women. Compared with non-Māori women, Māori women are at much higher risk of death from this cause (Table D19). Māori men have the highest rate of death from ischemic heart disease, but the disparity compared with non-Māori men, while high, is not as great as the disparity between the two groups of women. The mortality rate for Māori women almost equals the rate for non-Māori men.

The seriousness of ischemic heart disease as a cause of premature death among all women has until recently been overshadowed by the high incidence of the condition in men. The result has been that gender specific factors affecting prevalence, outcome and treatment have not been recognised. Gender specific risk factors for ischemic heart disease are: smoking, hypertension, high serum cholesterol, diet and weight, use of oral contraceptives, and diabetes.

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Cervical cancer
Compared with non-Māori women, Māori women are at increased risk of death from cervical cancer(Table D19). Malignant neoplasms of the cervix have been a leading cause ofdeath for Māori womenfor many years.

Lung cancer
The rate of deaths for Māori women from lung cancer is exceeded only by the rate for Māori men. The rate for Māori women is over three times the rate for non-Māori women (Table D19). Between 1988 and 1993, the incidence of lung cancer among Māori increased, whereas it decreased among non-Māori. Thus the disparity between Māori and non-Māori increased over this time. (Te Puni Kōkiri (2000a).)

The incidence of lung cancer is largely attributable to smoking. As with other smoking related diseases (such as chronic obstructive respiratory disease), differences between women's and men's smoking rates mean that Māori women's death rates from lung cancer will continue to rise.

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8. Discussion

Māori women recognise the value of being healthy. (North Health (1996).) The premature deaths of Māori women, at whatever age, mean the loss of kuia. This has a detrimental effect upon Māori society. In addition, as Māori women are the cornerstones of whānau, their ill health impacts on a number of lives.

Māori women's and men's differing experiences of the determinants of health, and the effect on Māori women's access to health services, have not yet been systematically addressed by health policy. Where the determinants of health and health services benefit women, they benefit the health and well-being of all New Zealanders. Gender itself must therefore be seen as a determinant of health.

Current prevention strategies may not be working as well for Māori women as for men in some areas. For example, Māori women's current smoking rates are higher than those of Māori men. More carefully targeted prevention strategies, based on Māori women's unique risk profile, appear torequired.

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8.1 Health, deprivation and ethnicity

It is now widely acknowledged that the wider social, economic and cultural determinants contributeinequalities in health outcomes. Health inequalities do not just occur among individuals. People living in deprived areas are more likely to have poor health and shorter lives. (National Health Committee (2000).) For Māori, deprivation prevents whānau from being able to function effectively, in terms of meeting cultural expectations, such as attending tangi. The obligations of manaakitanga (hospitality) are also difficult to fulfil.continues to isolate whānau and weaken their esteem. Thus the health of Māori women as a group, and their socio-economic status, are interwoven.

Analyses using the New Zealand Deprivation Index (NZDep96) demonstrate that the poor health of Māori women is not explainable solely by the effects of socio-economic deprivation. Ethnicity itself has an additional impact on Māori women's health status. Following their examination of the impact of social and economic disparities on health, Howden-Chapman and Tobias (2000) conclude that: "Socioeconomic factors do not, however, explain all of the health disparity for Māori and Pacific peoples. Part of the explanation may lie instead in the way our societal arrangements tend to favour the majority population, thus perpetuating inequalities between ethnic groups. (Howden-Chapman & Tobias (2000), p.162.) "

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8.2 Child morbidity and mortality

Māori children are over-represented in hospitalisation rates for preventable childhood conditions such as meningococcal disease, acute respiratory infections and asthma. These conditions have a direct link to poor and overcrowded housing. However, some hospitalisations could be avoided with early intervention and improved access to primary care via a general practitioner.

The connection between suicide or attempted suicide by young people and abuse needs to be investigated when reliable child abuse statistics become available. The links between child abuse, mental illness, socio-economic pressures and systemic racism also need to be investigated. (Jones (1999).) Suicide prevention strategies and community interventions are also addressing this tragedy.

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8.3 Adult morbidity and mortality

The morbidity issues raised in this chapter, and the causes of Māori women's premature death, are of particular interest in view of the potential preventability of deaths. The focus on major fatal diseases should be balanced by concern with the prevention of chronic disabling but non-fatal conditions.

Potentially avoidable mortality and potential avoidable hospitalisations are likely to have a complex web of causation, underpinned by economic and social factors. (Ministry of Health (2000a).) Most of the priority population healthobjectives in the New Zealand Health Strategy (Ministry of Health (2000b).) should contribute positively to Māori women's health and reduce their morbidity and mortality, in particular the objectives to reduce diabetes, cancer, cardiovascular disease impact, smoking and violence.

Cancer is the leading cause of Māori women's premature death. Cancers have a major impact on women's health, both as a cause of premature death and as a cause of suffering and long term health impairment. Public health programmes need to focus attention on those factors that may predispose Māori women to contracting cancer. Specific strategies should be developed to increase Māori women's participation rates in cancer screening programmes.

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Heart disease

Public health programmes need to focus attention on those factors that predispose Māori women to develop ischemic heart disease. There are strong indications that women with ischemic heart disease experience different patterns of diagnosis, different treatments and hospital courses, and different long-term outcomes from men with this type of disease. Further investigation is necessary to better define the gender-related differences and possible gender specific therapies for ischemic heart disease in Māori women.

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8.4 Smoking

Smoking has been identified as the single largest preventable factor in Māori women's premature death, disability and disease. The women who are most likely to start smoking are those in low-status jobs, on low incomes, single, separated or divorced, or victims of domestic violence. Once addicted, they are unlikely to stop using tobacco unless their circumstances change. As very few people begin to use tobacco after their teens, it is widely agreed that the greatest impact on smoking related mortality and morbidity would be achieved by preventing young people from beginning to smoke.

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8.5 Use of health services

Older Māori women do not seem to be accessing health services to the extent that they should be, given the state of their health. For example, Māori women receive coronary artery surgery at half the rate of non-Māori women, despite being at much higher risk of coronary disease. The barriers to Māori women receiving health care in this area need to be investigated and addressed.

The data indicates that Māori women's use of hospital services is less than proportionate to their generally greater need for health care services. Māori women may experience greater barriers to access to health services than non-Māori women. Health services may be culturally inappropriate or difficult for women to reach.

According to results from the 1996/97 New Zealand Health Survey, 18.6% of Māori reported unmet health needs (i.e. they needed to see a GP but did not). This was one and a half times the unmet need rate for the European/Pakeha ethnic group. Amongst other things, respondents cited factors such as cost, accessibility and appropriateness as reasons for not seeing a GP (Ministry of Health (1999b).)

Use of GP services also depends to some extent on whether a GP is available, the cost of consultation, cultural beliefs, and how the importance of illness is perceived. Shame and embarrassment prevent many women from seeking treatment for gynaecological conditions, including sexually transmitted infections, and also seeking help and protection against violence.

Māori women are subject to barriers put up against them not only as women, but also as Māori. While it is becoming more common for women to have access to female doctors, it is very rare that Māori women have the choice of Māori women health professionals. In addition there are very few Māori women in decision-making and policy-making positions at a national level.

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Data sources

The New Zealand Health Information Service's database The National Minimum Dataset, (NMDS) was used for most data. 1997 was the only year made available. The Ministry of Health adopted the Standard Classification of Ethnicity in 1996/97. As a consequence, limited time series data is available using the standard classification.

Life expectancy and fertility rates were provided by Statistics New Zealand. As noted for Table D1, Life expectancy rates are derived from official life tables and are based on three-year periods centring on a census year, hence 1995-97 is the most recent period available. Environmental Science and Research Ltd provided meningococcal disease hospitalisation data covering 1996-1999.

Health data is classified according to International Classification of Diseases (ICD) coding system.This is a World Health Organisation (WHO) classification system used internationally for coding health data.

Mortality data is coded from death registrations (and the appropriate death certificates) provided by Births Deaths and Marriages. Clinical coders use the information on the death certificates, from any other appropriate sources (hospital events, cancer registry, Water Safety Council, Land Transport Safety Authority, media search), and from the coroner's reports (where a coroner's verdict is required), in order to assign the most accurate code possible.

All malignant cancers are required to be registered under the Cancer Registry Act 1994, and reported to the Cancer Registry. The Cancer Registry employs clinical coders whose job it is to assign the correct cancer codes to each cancer registration. While a large number of cases are identified via the hospital discharge data initially, laboratories also report any cancers they diagnose.

Hospital data covers public hospitals only, and is coded by clinical coders staffed in each public hospital. These coders look at the patients' records and charts and record the appropriate ICD codes on their local Patient Management System (PMS). On a regular basis, all new/updated records are extracted from the PMS (by the hospital) and submitted electronically to the NMDS which houses the central database of hospital discharges. The New Zealand Health Information Service manages the database and extracts hospital information from that. In order to ensure the highest possible coding accuracy, clinical audit teams periodically audit coding in hospitals.

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