When the baby comes, amid contractions and labor-related anxiety, few would think of calling a phone number to assess whether they should head to the maternity ward (or not). In Portugal, that is currently the reality for many pregnant women.

Indeed, this is the focus of a pilot currently trialed in Lisbon, Portugal. In this pilot, pregnant women must call a triage hotline to be accepted into the emergency room. If the case is deemed an emergency, the woman is directed to a specific ward according to availability, whereby the ward receives the incoming mother’s information. In case the woman’s situation is deemed non-urgent, an appointment is scheduled within 48 hours. The hotline’s goal is to reduce the number of specialists needed in the emergency room, by reducing the influx of expectant mothers and better distributing them between wards.

This pilot was introduced as a response to the chronic closing of maternity wards in the country. The reason for the closures: a shortage of specialist doctors to ensure the (permanent) functioning of wards. In 2021, the number of labor specialists per 100,000 fertile women was already almost half of the European average, standing at 9.7. In 2023, this number had decreased further to 2.9. Reasons for this sudden decrease are still understudied, but may be associated with brain drain, and the retirement of specialists (as of 2021, over 38% of obstetricians and gynecologists were older than 65, a number which rose to 41% in 2023 – the  official retirement age is 66 years and 7 months). In line with this increasing shortage, access to care  decreased: in 2023, already 90.5% of fertile women had moderate to very low geographical access to public obstetrics care (as compared to 69.6% in 2021). These dire numbers are accompanied by recurrent news articles describing chaos and burnout at the maternity wards that remain open.

Rotation system

To adapt to this “not so brave new” reality, a rotating system of (open) maternity wards has been introduced over the past years, prior to the current pilot. However, this system is just a band-aid solution with plenty of negative implications for pregnant women, infants, and providers. Several scandals were already noted under this system, including the death of a 34-year-old laboring woman, while in transport between facilities due to overcrowding. This led to the resignation of the health minister (Marta Temido) in 2022. This “birth-in-transit” episode was not an isolated case, however: between January and August 2024, 40 babies were born in ambulances, transiting between hospitals. Caesarean rates increased in the public sector, which may or may not be linked to this system. Yet, emergency caesareans suffered a stark increase from 53.9% in 2021 to 65.2% of caesareans in 2023, at least suggesting that access to care is being delayed. Moreover, the national neonatal death rate increased from 0,39% of births in 2022 to 0,52% of live births in 2023. In Lisbon, this rate almost doubled in the same time period. Specialists claimed in-depth analysis must take place to conclude whether the rotation system of maternity wards is behind this trend. A year later, no explanations have been provided yet.

The pilot: more than yet another band-aid solution?  

The new trial piloted in Lisbon has been presented as a solution to the rotation system. Although the trial is still ongoing, some preliminary results are already available: during the first 10 days, 73% of women calling the hotline were directed to a ward, and doctors in central wards spotted a decrease in births of 40%, indicating that the pilot is reducing the influx of pregnant women. Whether this is a positive result or not, can only be known from the pilot’s impact on perinatal health outcomes which are not yet available. Improved health outcomes are, however, expected from increasing access, not just from reducing early care seeking (which had not been pointed out as an issue before). Nevertheless, complaints about the new model are mainly “pilot hiccups” so far:  hotline waiting times, and mothers arriving at the ward and being forced to call the hotline to be allowed in. These issues have not been mentioned anymore in the media since the first weeks, indicating that the hotline system might indeed “work”. But can this really be a permanent solution? Does the answer rely on solely reducing the influx of pregnant women? Although the findings from this pilot may provide some positive temporary improvements, setting up just a triage hotline feels like yet another band-aid solution.

Tackling the root cause of the problem

A more permanent solution should strive to fix the human resources issue at the root of this problem. The minister of health has announced that more specialists will be hired, but where will they come from? Certainly not from the private sector, as the public sector can’t match their salaries for the time being. “Importing” specialists shouldn’t be the solution either, as most of these professionals seem to end up in the private sector. Although additional adjustments could be made to optimize care, such as increasing nurses’ and midwives’ autonomy, a key aspect of the  solution seems straightforward: salary increases for public sector doctors. Indeed, Portuguese public sector doctors happen to be among the least well paid ones in Europe, despite the country’s above-European-average spending in healthcare as a share of GDP.  In other words, the HR problem is not due to a small healthcare budget, but rather due to its poor management, at the expense of public health doctors’ salaries. Therefore, with the pilot coming to an end, the Portuguese government shouldn’t be satisfied with positive results (although they’re obviously welcome), but keep fighting to improve care through the retainment of specialists.

Jumping between band-aid-solutions cannot be a long-term option.