When the NHS closes itself off to women in vulnerable situations

Caring requires presence. Listening. Acceptance. But many pregnant women face a system that doesn't see them, doesn't understand them, and, worse, doesn't support them.

In early July, a 31-week pregnant woman living in Barreiro called SNS24 due to strong contractions and decreased fetal activity. She was referred to Santa Maria Hospital in Lisbon—about 60 kilometers away—without anyone confirming whether she had transportation, support, or even the means to get there. Even after mentioning her financial resources, the response was to hang up. With no alternative, she called 112. Hours later, she arrived at Cascais Hospital. With the diagnosis of placental abruption, it was too late. The baby no longer showed signs of life.

And this isn't an isolated case. As a maternal health nurse, I frequently see pregnant women in similar situations: alone, without transportation, lacking health literacy, lacking language proficiency, and confronted with a system that presumes autonomy where only vulnerability—linguistic, social, and economic—exists.

The Barreiro case, tragic as it is, is merely the visible face of a deeper problem: deficient prenatal surveillance in primary health care. That's where it all begins—or should begin. When pregnancies aren't monitored with quality and close care, risks silently accumulate until they emerge acutely in hospital emergency rooms. These aren't isolated failures, but rather a system that leaves these women behind from the start.

On the South Bank, many women face multiple barriers: social vulnerability, insufficient medical care, language barriers, and uncertainty about where they will give birth. A significant proportion come from countries like Angola, Guinea, Nepal, and Bangladesh, arriving in Portugal pregnant, without vaccinations, prenatal appointments, and with undiagnosed pathologies. For many, pregnancy is their first contact with the NHS.

And this first contact, in most cases, occurs in a Personalized Healthcare Unit (UCSP). Many of these units operate without family doctors and with small nursing teams, few of which are specialists in maternal health and obstetrics. Even so, these professionals have the legal authority to monitor low-risk pregnancies—a practice already established in several European countries. In Portugal, this authority is provided for in Regulation No. 391/2019, published in the Official Gazette. However, its practical application continues to be limited by the regulatory authorities, which acknowledge this limitation. Even when monitored by other strategic sectors, organizational and budgetary constraints persist. The result? Poorly monitored pregnancies that increase clinical risk at the time of delivery—for both mother and baby.

The Barreiro case exposes a structural weakness: the reliance on algorithms that fail to account for situations outside the norm. SNS24 followed protocol—but ignored the essentials. It failed to ask if transportation, support, or resources were available. And when the automated solution didn't work, the system didn't know what to do. It shut down. The integrated response failed. The technology, which was supposed to support, became a barrier.

This failure is compounded by a growing demographic reality. The municipalities of Almada, Seixal, Barreiro, Moita, Montijo, Alcochete, and Setúbal—covered by the Almada-Seixal, Arco Ribeirinho, and Arrábida Local Health Units (ULS)—are experiencing a significant increase in their foreign population. In 2023, the Setúbal Peninsula reached 11.9% foreign residents, one of the highest rates in the country. In Montijo, more than 1 in 9 inhabitants is an immigrant. Almada leads in RSI allocation. Populations without a network, without a doctor, without transportation—but subject to protocols that assume otherwise.

The three ULS (State Health Units) on the South Bank—Almada-Seixal, Arco Ribeirinho, and Arrábida—together cover more than 1,160 square kilometers and are home to approximately 775,000 people. This vast and densely populated territory, with a large presence of immigrant communities, requires an organized territorial response—not isolated or centralized adaptations.

At the UCSP (University of São Paulo) where I work, the Arco Ribeirinho University Hospital in Barreiro, with over 23,000 patients—many of them foreigners, with limited financial resources, and without family support—the shortage is palpable. We have only nine nurses, of whom almost half are absent for long periods. According to Order No. 9490/2019, at least fifteen would be needed to ensure minimum safe care. We are far from that number.

Within the same territory, USF and UCSP coexist under the same umbrella and funding, but with different logics and incentives. USFs accommodate stable patients with fixed addresses and greater predictability. They work with indicators that translate into performance bonuses. UCSPs, on the other hand, receive the system's "nomads"—immigrants, families on the move, people with no known medical history—without a proportional increase in resources. The inequality here is institutional.

And this inequality also affects professionals. Those on the front lines—with greater workload, greater complexity, and fewer conditions—receive no additional recognition. They receive only a base salary, regardless of effort, risk, or responsibility. The consequence? Disruption. Exhaustion. Burnout. And, above all, a broken bond with those who need support most.

This logic urgently needs to be rethought. In an attempt to address the most pressing problem—the shortage of professionals that leads to constant constraints in obstetric emergencies—the Socialist Party government, under the leadership of then-Prime Minister António Costa, appointed a commission led by Dr. Diogo Ayres de Campos. The resulting report, entitled "Hospital Referral Network for Obstetrics, Gynecology, and Neonatology ," was published by the NHS in February 2023 and proposes two main approaches: (1) improving the working conditions and remuneration of healthcare professionals, particularly obstetricians, with a view to retaining them in the NHS; or (2) concentrating human resources in a single hospital unit per region, as is already the case with other services in Lisbon and Porto. It is important to note that this study, although prepared under the guidance of the previous government, continues to integrate the strategic thinking and plans of the current government and remains present in the ongoing guidelines of the Ministry of Health.

However, this second solution ignores the territorial realities. In the South Bank, the distances between hospitals are significant, access is often congested, and travel costs fall on professionals—without any compensation. Furthermore, many of these professionals have individual employment contracts and are not covered by the mobility law, meaning they cannot be legally required to travel between institutions. Forcing this mobility can generate discontent, instability, and accelerate the abandonment of the public sector in favor of the private sector or emigration.

What is urgently needed to change?

• Restructure careers, with fair incentives for those working in underserved areas or with rotating schedules. Work-life balance must be part of the equation. The concept of "Magnet" hospitals—which value the well-being and development of their professionals—is an inspiring example that should be considered.

• Restructure the SNS24 hotline for pregnant women, with interpreters, culturally sensitive screening, and a genuine response capacity for those who do not speak the language or lack autonomy.
• Create mechanisms to support health mobility, with guaranteed and free transportation for pregnant women referred outside their area of residence.
• Ensure the continuous operation of obstetric emergencies in the South Bank, avoiding unsafe and unnecessary transfers.
• Invest in maternal health literacy programs, built in partnership with associations, local authorities, and communities.
• Eliminate inequalities between USF, UCSP, and UCC within the same ULS, creating an equitable financing and incentive model that recognizes the complexity of the most vulnerable contexts.
• Strengthen the teams at the São Paulo State University Hospitals (UCSP) in the South Bank, complying with Order No. 9490/2019 on safe staffing. This is the only way to ensure safe and ethical care.
• Create an Integrated Responsibility Center (CRI) specifically for pregnant women in vulnerable situations, with multidisciplinary teams, dedicated funding, and coordination between the UCSP, hospital emergency departments, and the social network, ensuring early surveillance, continuity of care, and a rapid response in critical situations.
• Adapt health policies to territorial realities, abandoning centralist logic and assuming that an effective response must be tailored to the territory.

I wasn't trained to say "there's nothing to do." I was trained to care. And caring, in this context, is resistance.

It is resisting the bureaucracy that does not listen. It is to resist the inertia that abandons.

It is resisting the indifference that kills.

But resistance is no longer enough. We must demand.

This article isn't a rant. It's a commitment: to demand structured, competent, and humane support, regardless of origin, language, or social status.

As a society, it is our duty to act — before the next tragedy happens again.