Maternity services in Australia are in urgent need of change. During the last 10 years several reviews have highlighted the need to provide more continuity of care for women in conjunction with the rationalisation of services. One solution may lie in the development of new integrated systems of care where primary-level maternity units offer midwifery-led care and women are transferred into perinatal centres to access tertiary-level obstetric technology and staff when required. This case study outlines the introduction of caseload midwifery into an Area Health Service in metropolitan Sydney. Our objective is to explore the concept of caseload midwifery and the process of implementing the first midwifery-led unit in NSW within an integrated service network. The midwife-led unit is a small but growing phenomenon in many countries. However, the provision of "continuity" and "woman-centred" midwifery care involves radical changes to conventional hospital practice.