This paper critically examines pregnancy health care and services for Aboriginal and Torres Strait Islander women, to explore the question of what might 'make a difference'. More antenatal care and in particular Aboriginal women attending for care earlier and more often, is often put forward as what is needed to improve pregnancy outcomes, as well as the health of future populations. However, evidence from epidemiological, clinical and health services research problematises this assertion. An alternative and preferable driver for the reform of maternity services for Aboriginal women would be to allow women themselves to have more said in decision making at both individual and institutional levels.