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Nurses and midwives of Australia now is the time for change! As powerfully placed, Indigenous and non-Indigenous nursing and midwifery professionals, together we can ensure an effective and robust Indigenous curriculum in our nursing and midwifery schools of education. Today, Australia finds itself in a shifting tide of social change, where the voices for better and safer health care ring out loud. Voices for justice, equity and equality reverberate across our cities, our streets, homes, and institutions of learning. It is a call for new songlines of reform. The need to embed meaningful Indigenous health curricula is stronger now than it ever was for Australian nursing and midwifery. It is essential that nursing and midwifery leadership continue to build an authentic collaborative environment for Indigenous curriculum development. Bipartisan alliance is imperative for all academic staff to be confident in their teaching and learning experiences with Indigenous health syllabus. This paper is a call out. Now is the time for Indigenous and non-Indigenous nurses and midwives to make a stand together, for justice and equity in our teaching, learning, and practice. Together we will dismantle systems, policy, and practices in health that oppress. The Black Lives Matter movement provides us with a ‘now window’ of accepted dialogue to build a better, culturally safe Australian nursing and midwifery workforce, ensuring that Black Lives Matter in all aspects of health care.

Objectives: To explain vaccination refusal in a sample of Australian parents. Design: Qualitative design, purposive sampling in a defined population. Setting: A geographically bounded community of approximately 30 000 people in regional Australia with high prevalence of vaccination refusal. Participants: Semi structured interviews with 32 non-vaccinating parents: 9 fathers, 22 mothers and 1 pregnant woman. Purposive sampling of parents who had decided to discontinue or decline all vaccinations for their children. Recruitment: via local advertising then snowballing. Results: Thematic analysis focused on explaining decision-making pathways of parents who refuse vaccination. Common patterns in parents' accounts included: perceived deterioration in health in Western societies; a personal experience introducing doubt about vaccine safety; concerns regarding consent; varied encounters with health professionals (dismissive, hindering and helpful); a quest for the real truth'; reactance to system inflexibilities and ongoing risk assessment. Conclusions: We suggest responses tailored to the perspectives of non-vaccinating parents to assist professionals in understanding and maintaining empathic clinical relationships with this important patient group.

Objective: To describe the outcomes of a public hospital maternity unit in rural New South Wales (NSW) following the adaptation of the service from an obstetrician and general practitioner-obstetrician (GPO)-led birthing service to a low-risk midwifery group practice (MGP) model of care with a planned caesarean section service (PCS). Design: A retrospective descriptive study using quantitative methodology. Setting: Maternity unit in a small public hospital in rural New South Wales, Australia. Participants: Data were extracted from the wardbased birth register for 1172 births at the service between July 2007 and June 2012. Main outcome measures: Birth numbers, maternal characteristics, labour, birthing and neonatal outcomes. Results: There were 750 births over 29 months in GPO and 277 and 145 births over 31 months in MGP and PCS, respectively, totalling 422 births following the change in model of care. The GPO had 553 (73.7%) vaginal births and 197 (26.3%) caesarean section (CS) births (139 planned and 58 unplanned). There were almost universal normal vaginal births in MGP (>99% or 276). For normal vaginal births, more women in MGP had no analgesia (45.3% versus 25.1%) or non-invasive analgesia (47.9% versus 38.6%) and episiotomy was less common in MGP than GPO (1.9% versus 3.4%). Neonatal outcomes were similar for both groups with no difference between Apgar scores at 5 min, neonatal resuscitations or transfer to high-level special care nurseries. Conclusion: This study demonstrates how a rural maternity service maintained quality care outcomes for low-risk women following the adaptation from a GPO to an MGP service.

Objective There is a need to adapt pathways to care to promote access to mental health services for Indigenous people in Australia. This study explored Indigenous community and service provider perspectives of well-being and ways to promote access to care for Indigenous people at risk of depressive illness.Design A participatory action research framework was used to inform the development of an agreed early intervention pathway; thematic analysisSetting 2 remote communities in the Northern Territory.Participants Using snowball and purposive sampling, 27 service providers and community members with knowledge of the local context and the diverse needs of those at risk of depression were interviewed. 30% of participants were Indigenous. The proposed pathway to care was adapted in response to participant feedback.Results The study found that Indigenous mental health and well-being is perceived as multifaceted and strongly linked to cultural identity. It also confirms that there is broad support for promotion of a clear pathway to early intervention. Key identified components of this pathway were the health centre, visiting and community-based services, and local community resources including elders, cultural activities and families. Enablers to early intervention were reported. Significant barriers to the detection and treatment of those at risk of depression were identified, including insufficient resources, negative attitudes and stigma, and limited awareness of support options.Conclusions Successful early intervention for well-being concerns requires improved understanding of Indigenous well-being perspectives and a systematic change in service delivery that promotes integration, flexibility and collaboration between services and the community, and recognises the importance of social determinants in health promotion and the healing process. Such changes require policy support, targeted training and education, and ongoing promotion.

Background Across Australia there are substantial disparities in uptake of antenatal testing for fetal anomalies, with very low uptake observed among Aboriginal women. The reasons behind these disparities are unclear, although poorer access to testing has been reported in some communities. We interviewed health care practitioners to explore the perceived barriers to providing fetal anomaly screening to Aboriginal women. Methods In 2009 and 2010, in-depth interviews were undertaken with 59 practitioners in five urban and remote sites across the Northern Territory (NT) of Australia. Data were analyzed thematically. Maximum variation sampling, independent review of findings by multiple analysts, and participant feedback were undertaken to strengthen the validity of findings. Results Participants included midwives (47%), Aboriginal health practitioners (AHP) (32%), general practitioners (12%), and obstetricians (9%); almost all (95%) were female. Participants consistently reported difficulties counseling women. Explaining the concept of "risk" (of abnormalities and the screening test result) was identified as particularly challenging, because of a perceived lack of an equivalent concept in Aboriginal languages. While AHPs could assist with overcoming language barriers, they are underutilized. Participants also identified impediments to organizing testing including difficulties establishing gestational age, late presentation for care, and a lack of standardized information and training. Discussion The availability of fetal anomaly testing is challenged by communication difficulties, including a focus on culturally specific biomedical concepts, and organizational barriers to arranging testing. Developing educational activities that address the technical aspects of screening and communication skills will assist in improving access. These activities must include AHPs.

Australia has a well-accepted system of universal child and family health (CFH) services. However, government reports and research indicate that these services vary across states and territories, and many children and families do not receive these services. The aim of this paper was to explore professionals' perceptions of the challenges and opportunities in implementing a national approach to universal CFH services across Australia. Qualitative data were collected between July 2010 and April 2011 in the first phase of a three-phase study designed to investigate the feasibility of implementing a national approach to CFH services in Australia. In total, 161 professionals participated in phase 1 consultations conducted either as discussion groups, teleconferences or through email conversation. Participants came from all Australian states and territories and included 60 CFH nurses, 45 midwives, 15 general practitioners (GPs), 12 practice nurses, 14 allied health professionals, 7 early childhood education specialists, 6 staff from non-government organisations and 2 Australian government policy advisors. Data were analysed thematically. Participants supported the concept of a universal CFH service, but identified implementation barriers. Key challenges included the absence of a minimum data set and lack of aggregated national data to assist planning and determine outcomes; an inconsistent approach to transfer of information about mothers and newborns from maternity services to CFH nursing services or GPs; poor communication across disciplines and services; issues of access and equity of service delivery; workforce limitations and tensions around role boundaries. Directions for change were identified, including improved electronic data collection and communication systems, reporting of service delivery and outcomes between states and territories, professional collaboration, service co-location and interprofessional learning and development.

BackgroundHealth services research is a well-articulated research methodology and can be a powerful vehicle to implement sustainable health service reform. This paper presents a summary of a five-year collaborative program between stakeholders and researchers that led to sustainable improvements in the maternity services for remote-dwelling Aboriginal women and their infants in the Top End (TE) of Australia. MethodsA mixed-methods health services research program of work was designed, using a participatory approach. The study area consisted of two large remote Aboriginal communities in the Top End of Australia and the hospital in the regional centre (RC) that provided birth and tertiary care for these communities. The stakeholders included consumers, midwives, doctors, nurses, Aboriginal Health Workers (AHW), managers, policy makers and support staff. Data were sourced from: hospital and health centre records; perinatal data sets and costing data sets; observations of maternal and infant health service delivery and parenting styles; formal and informal interviews with providers and women and focus groups. Studies examined: indicator sets that identify best care, the impact of quality of care and remoteness on health outcomes,  discrepancies in the birth counts in a range of different data sets and ethnographic studies of ‘out of hospital’ or health centre birth and parenting. A new model of maternity care was introduced by the health service aiming to improve care following the findings of our research. Some of these improvements introduced during the five-year research program of research were evaluated. ResultsCost effective improvements were made to the acceptability, quality and outcomes of maternity care. However, our synthesis identified system-wide problems that still account for poor quality of infant services, specifically, unacceptable standards of infant care and parent support, no apparent relationship between volume and acuity of p

Introduction: The closure of rural maternity units in Australia means an increasing number of women are transferred into major centres to await birth. Accurately excluding the onset of labour could delay relocation. The fetal fibronectin (fFN) test is used to predict preterm birth; however, the accuracy of this test for determining impending term birth is unclear.Methods: In all 75 women were recruited to this study from two remote maternity units. Eligibility criteria were: aged ≥18 years, singleton pregnancy, 37+0–40+3 weeks (37 weeks to 40 weeks and 3 days gestation) and no indication for induction of labour or caesarean section in next 7 days. The Quikcheck fFN® test was performed at 37 weeks and then repeated at 7 day intervals. Time-to-birth from test date was modelled using linear regression. Logistic regression models estimated odds of birth within 7 days. Separate models considered first and last test results and those at 38 weeks; adjusted for use of lubricant and gestational age.Results: A shorter time-to-birth was found in women with positive compared with negative fFN tests; significant at first fFN test (adjusted mean difference [AMD] 5.4 days, 95% CI 2.0-8.8) and 38 weeks (AMD 5.7 days, 95% CI 2.2-9.2 days). A positive test was also associated with a significant increase in the odds of birthing within 7 days: first fFN test adjusted odds ratio (AOR) 11.0 (95% CI 2.5-48.7), 38 weeks test AOR 14.4 (95% CI 3.4-60.2), last fFN test AOR 8.1 (95% CI 1.6-39.8). However, of women who gave birth within 7 days of testing a significant proportion had a negative fFN result; first fFN test 8/17(47.1%), 38 weeks test 4/14(28.6%) and last fFN test 29/58(50.0%).Conclusion: The presence of fFN in cervical secretions was associated with impending term birth but its absence did not reliably exclude the onset of birth. Delaying transfer based on these findings would result in some women birthing in their home communities.

BackgroundComparisons of birth outcomes between Australian Indigenous and non-Indigenous populations show marked inequalities. These comparisons obscure Indigenous disparities. There is much variation in terms of culture, language, residence, and access to services amongst Australian Indigenous peoples. We examined outcomes by region and remoteness for Indigenous subgroups and explored data for communities to inform health service delivery and interventions. MethodsOur population-based study examined maternal and neonatal outcomes for 7,560 mothers with singleton pregnancies from Australia’s Northern Territory Midwives’ Data Collection (2003–2005) using uni- and multivariate analyses. Groupings were by Indigenous status; region (Top End (TE)/Central Australia (CA)); Remote/Urban residence; and across two large TE communities. ResultsOf the sample, 34.1% were Indigenous women, of whom 65.6% were remote-dwelling versus 6.7% of non-Indigenous women. In comparison to CA Urban mothers: TE Remote (adjusted odds ratio [aOR] 1.47, 95%CI: 1.13, 1.90) and TE Urban mothers (aOR 1.36 (95% CI: 1.02, 1.80) were more likely, but CA Remote mothers (aOR 0.43; 95% CI: 0.31, 0.58) less likely to smoke during pregnancy; CA Remote mothers giving birth at >32 weeks gestation were less likely to have attended ≥ five antenatal visits (aOR 0.55; 95%CI: 0.36, 0.86); TE Remote (aOR 0.71; 95%CI: 0.53, 0.95) and CA Remote women (aOR 0.68; 95%CI: 0.49, 0.95) who experienced labour had lower odds of epidural/spinal/narcotic pain relief; and TE Remote (aOR 0.47; 95%CI: 0.34, 0.66), TE Urban (aOR 0.67; 95%CI: 0.46, 0.96) and CA Remote mothers (aOR 0.52; 95%CI: 0.35, 0.76) all had lower odds of having a ‘normal’ birth. The aOR for preterm birth for TE Remote newborns was 2.09 (95%CI: 1.20, 3.64) and they weighed 137 g (95%CI: -216 g, -59 g) less than CA Urban babies. There were few significant differences for communities

BackgroundAustralia is a wealthy developed country. However, there are significant disparities in health outcomes for Aboriginal infants compared with other Australian infants. Health outcomes tend to be worse for those living in remote areas. Little is known about the health service utilisation patterns of remote dwelling Aboriginal infants. This study describes health service utilisation patterns at the primary and referral level by remote dwelling Aboriginal infants from northern Australia. ResultsData on 413 infants were analysed. Following birth, one third of infants were admitted to the regional hospital neonatal nursery, primarily for preterm birth. Once home, most (98%) health service utilisation occurred at the remote primary health centre, infants presented to the centre about once a fortnight (mean 28 presentations per year, 95%CI 26.4-30.0). Half of the presentations were for new problems, most commonly for respiratory, skin and gastrointestinal symptoms. Remaining presentations were for reviews or routine health service provision. By one year of age 59% of infants were admitted to hospital at least once, the rate of hospitalisation per infant year was 1.1 (95%CI 0.9-1.2). ConclusionsThe hospitalisation rate is high and admissions commence early in life, visits to the remote primary health centre are frequent. Half of all presentations are for new problems. These findings have important implications for health service planning and delivery to remote dwelling Aboriginal families.

Context: The reproductive health outcomes for Aboriginal and Torres Strait Islander mothers and infants are significantly poorer than they are for other Australians; they worsen with increasing remoteness where the provision of services becomes more challenging. Australia has committed to ‘Overcoming Indigenous Disadvantage' and ‘Closing the Gap’ in health outcomes.Issues: Fifty-five per cent of Aboriginal and Torres Strait Islander birthing women live in outer regional and remote areas and suffer some of the worst health outcomes in the country. Not all of these women are receiving care from a skilled provider, antenatally, in birth or postnatally while the role of midwives in reducing maternal and newborn mortality and morbidity is under-utilised. The practice of relocating women for birth does not address their cultural needs or self-identified risks and is contributing to these outcomes. An evidence based approach for the provision of maternity services in these areas is required. Australian maternal mortality data collection, analysis and reporting is currently insufficient to measure progress yet it should be used as an indicator for ‘Closing the Gap’ in Australia. Lessons learned: A more intensive, coordinated strategy to improve maternal infant health in rural and remote Australia must be adopted. Care needs to address social, emotional and cultural health needs, and be as close to home as possible. The role of midwives can be enabled to provide comprehensive, quality care within a collaborative team that includes women, community and medical colleagues. Service provision should be reorganised to match activity to need through the provision of caseload midwives and midwifery group practices across the country. Funding to embed student midwives and support Aboriginal and Torres Strait Islander women in this role must be realised. An evidence base must be developed to inform the provision of services in these areas; this could be

Aim. This paper is a report of a grounded theory study of woman's infant feeding experiences and decisions in the first 6 weeks after birth. Background. Breastfeeding is considered the optimum method of infant feeding. Studies have identified numerous factors associated with infant feeding decisions. What remains unexplored are the mechanisms by which socio-demographic, biomedical and psychosocial factors influence infant feeding decisions. Research highlights the need for further investigation of the experiences and decision-making processes of both breastfeeding and formula-feeding women. Method. A constructionist grounded theory approach to data collection and analysis was used. Data for this study were collected and analysed between 2003 and 2004. Further data, collected in a previous study in 2000, were theoretically sampled and analysed in 2005. In-depth interviews with 37 women from various socio-demographic areas in New South Wales, Australia provided data. Findings. The core category was 'deconstructing best'. 'Deconstructing best' was the infant feeding decision-making process in the first 6 weeks after birth. The process of 'deconstructing best' involved seven phases: planning, expecting, realizing, questioning, getting on with it, defending and qualifying. Four main categories -'it's really best to breastfeed', 'it's the unknown', 'it's not the only thing going on', and 'everybody's best is different'- comprised the context within which deconstructing best occurred. Conclusion. Woman's infant feeding decisions cannot be viewed in isolation from other post-natal experiences and needs. Infant feeding decisions will only be understood and appropriately supported when they are seen in relation to the circumstances of a woman's life, her immediate sociocultural context and individual experience.

Aim: to examine data collected during the testing of a new birth record in Jordan from 1 July to 31 August 2004, and to compare these practices with guidelines from the World Health Organization (WHO) and evidence-based recommendations. This was part of a larger study that used an action research approach to engage practitioners in implementation of the new record. Design: descriptive, comparative design. Setting: three Ministry of Health hospitals in Jordan. Participants: the birth records of 1254 mothers and babies were used. Measurements: data on selected labour and birth practices were collected from the records. Comparisons were made using recognised evidence-based guidelines. Findings: the rates of a number of labour and birth practices were inappropriately high, and differed from WHO guidelines and evidence-based recommendations. The rates of augmentation of labour (46%) and episiotomy (53%) were particularly high, and seem to be in excess of the WHO recommendations, which state that neither of these practices should be undertaken routinely. Implications for practice: information on labour and birth practices can assist clinicians working in these three hospitals to reflect upon their care and outcomes. Clinicians may be able to use this information to change practice to improve care for women and babies. Organisational support and clinical leadership are necessary in order to provide health professionals with time and resources to access research data and undertake comparisons that can lead to health service and system-level improvement.

INTRODUCTION: The Australian Agency for International Development (AusAID) funded Women and Children's Health Project sought to improve the health of women and children throughout Papua New Guinea between 1998 and 2004. The project utilised education, community development and health promotion interventions aimed to increase community support for the health of women and children. METHODS: An outcome evaluation in 2006 investigated the long-term impact of the project using a multi-methods approach and covering 10 selectively sampled provinces, 19 districts and 93 communities. Qualitative data were collected from 175 interviews (national to village level) and 77 community discussions. Quantitative data from national, provincial and district levels were examined to attempt to validate findings. RESULTS: The evaluation found new-health-knowledge initiated changes to lifestyle practices and improved physical health and social and economic well-being in villages where volunteers and staff had been trained. Factors influencing success were a health-motivated person acting as a catalyst for change, empowered leadership through new community governance structures, effective visual tools and village health volunteers linking community and rural health workers. Failure was attributed to poor understanding of community development, limited information sharing, a 'top down' approach to community development and weak community leadership. CONCLUSION: The project's community health interventions improved the interaction between the community and health system, and influenced improved use of maternal and child health services. Evaluation suggests sustainable improvements in health can be achieved through community led and maintained activity.

This article describes the practice—research engagement (PRE) that occurred during an action research project conducted in three hospitals in Jordan. The project aimed to develop and test the feasibility of an improved clinical record-keeping system. This article focuses on how relationships were built and evolved over time with national and local leaders and practitioners to facilitate the study, and how this led to a process of health system improvement. The article draws on outcomes and analyses from data collected in field notes, recorded interviews and focus groups. Results showed that the PRE approach assisted people to change as they undertook a process of clinical improvement and health systems development.

The maternity waiting home strategy was developed as a pilot project in Timor-Leste in 2005. The aim was to increase the utilisation of health facilities for birth, particularly for women living in rural and remote areas. The ultimate goal of maternity waiting homes was to reduce the high maternal and neonatal mortality rates observed throughout the country. This report provides an evaluation of the maternity waiting home strategy in Timor-Leste from 2005 to 2007.A mixed methods approach was used for this investigation. It consisted of 106 qualitative interviews in eight districts. These interviews explored why the strategy was or was not successful, and why some women chose to birth in a facility and others did not. A quantitative analysis of the number of births, deaths, referrals and user’s area of residence was conducted for two maternity establishments that have been functioning for longer than six months, namely Lospalos and Same.The findings show that:• The original maternity waiting home strategy has not been successful in Timor-Leste, despite the concept being piloted in two districts and being taken up by local authorities in four districts. This is because no maternity establishments are functioning as waiting homes. Instead, the maternity waiting home idea has been adapted to the local context and transformed into two different types of maternity establishments: accommodation services in Lospalos and stand-alone birth facilities in Same, Laleia and Bazartete. The maternity establishments in Cailaco and Atabae could not be evaluated as they are not yet functioning, despite construction being completed for one year and for six months, respectively.• Maternity establishments, backed by transport and promoted to the community, are associated with a modest increase in facility births in Same, but no such correlation is observed in Lospalos. Contrary to the objectives of the maternity waiting home strategy, women are not likely to attend a mate

Child and family health (C&FH) nurses and paediatric nurses are often grouped together because both professional groups work with children. The reality is, however, that many believe that the two nursing specialties are very different; this paper therefore aims to explore these differences. It focuses on issues around professional identity and the principles of partnership, including the difficulties faced by both groups embedding these principles into practice.

PurposeTo discuss cultural safety and critique the provision of culturally appropriate maternity services to remote Aboriginal and Torres Strait Islander women in Australia.ProcedureThe literature and policies around ‘culture’ and ‘cultural safety’ are discussed and applied to the provision of maternity services to Aboriginal and Torres Strait Islander women in remote areas of Australia.FindingsThe current provision of maternity services to Aboriginal and Torres Strait Islander women, particularly those living in remote Australia, appears largely inadequate. The provision of culturally safe maternity care requires health system reform at all levels including: the individual practitioner response; the educational preparation of practitioners; the delivery of maternity services and the development of policy at local, state and national level. This paper considers the changes that can be made from the individual practitioner through to the design and implementation of maternity services.Principal conclusionsCultural safety provides a useful framework to improve the delivery of maternity services to remote Aboriginal and Torres Strait Islander women and their families.

This qualitative research utilised a health services research framework and ethnographic methods to explore, describe and analyse contemporary child and family health (C&FH) nursing practice in an area of New South Wales, and identify the major factors that impact on their ability to effectively support families. The research identified the complexity of current C&FH nursing practice and changes in the philosophy that underpinned this at the policy level that were difficult to adopt. Despite a change in policy direction that advocated a partnership approach, nurses predominantly continue to frame their practice within an “expert” model. The nurses also struggled to deliver new service models while maintaining access for all families. Some explanations for the tensions experienced by the nurses relate to their age and educational preparation within the workforce. Other factors relate to the structures and management systems evident within the health service that employs them. To effectively support new families within the community, health systems must adequately resource services and support C&FH nurses in changing from a paradigm of expert to partner, consistent with primary health care practice.

INTRODUCTION: Telecommunication infrastructure is being rolled out across Australia with little knowledge about the uptake by health professionals in remote areas. Computer mediated communication has the potential to offer educational support to remote practitioners; however, the viability of this is uncertain. The aim of this research was to establish and evaluate an internet-based resource library targeting the needs of remote area maternity service providers. METHODS: A participatory action research (PAR) approach was used to involve remote area maternity service providers in the Northern Territory of Australia. The evaluation of the resource library included its performance on reach, agency affiliation and richness, factors identified to affect the sustainability and utility of such a resource. An additional component of the evaluation framework documented the facilitators of and barriers to using an information technology strategy to reduce the isolation of remote area maternity service providers. RESULTS: Overall, the evaluation of the resource library was very positive. Feedback from the PAR team described the resource as contemporary, useful and relevant. Practitioners in leadership and education positions identified the resource library as a valuable tool that enabled them to access professional knowledge, which could then be distributed to any remote-based practitioners, who experienced difficulties with access themselves. The evaluation found that logistical issues were a major problem for potential users. Hardware inadequacies, access difficulties, unfamiliarity with computers, and a lack of management support for nursing and midwifery staff to utilise the resource, were all identified barriers. Remote-area practitioners highlighted education, training and 24 hour support as key priorities. CONCLUSIONS: Results from this research clearly showed the potential of web-based resources to offer educational support through access to clinical guidelines, report

Traditional birth attendant (TBA) training commenced in many places in the non-Western world in the 1970s, supported by the World Health Organization and other funding bodies. By 1997, senior policy makers decided to refocus priorities on the provision of skilled attendants to assist birthing women. The definition of skilled attendants excluded TBAs and resulted in the subsequent withdrawal of funding for TBA training globally. A review of the health and sociological literature and international policy documents that address TBA training revealed how international policy and professional orientation are reflected in education programs designed for the TBA. Policy makers risk ignoring the important cultural and social roles TBAs fulfill in their local communities and fail to recognize the barriers to the provision of skilled care. The provision of skilled attendants for all birthing women cannot occur in isolation from TBAs who in themselves are also highly skilled. This article argues a legitimacy of alternative worldviews and acknowledges the contribution TBAs make to childbearing women across the world.

Objective: To test whether a new community-based model of continuity of care provided by midwives and obstetricians improved maternal clinical outcomes, in particular a reduced caesarean section rate.Design: Randomised controlled trial.Setting: A public teaching hospital in metropolitan Sydney, Australia.Sample: 1089 women randomised to either the community-based model (n=550) or standard hospital-based care (n=539) prior to their first antenatal booking visit at an Australian metropolitan public hospital.Main outcome measures: Data were collected on onset and outcomes of labour, antenatal, intrapartum and postnatal complications, antenatal admissions to hospital and neonatal mortality and morbidity.Results: There was a significant difference in the caesarean section rate between the groups, 13.3% (73/550) in the community-based group and 17.8% in the control group (96/539). This difference was maintained after controlling for known contributing factors to caesarean section (OR=0.6, 95% CI 0.4–0.9, P=0.02). There were no other significant differences in the events during labour and birth. Eighty babies (14.5%) from the community-based group and 102 (18.9%) from the control group were admitted to the special care nursery, but this difference was not significant (OR 0.75, 95% CI 0.5-1.1, P=0.12). Eight infants died during the perinatal period (four from each group), for an overall perinatal mortality rate of 7.3 per 1000 births.Conclusion: Community-based continuity of maternity care provided by midwives and obstetricians resulted in a significantly reduced caesarean section rate. There were no other differences in clinical outcomes.