The Portugal health sector faces a critical juncture as over 200 European obstetrics specialists and professional organizations challenge the European Commission's proposed update to midwifery qualification standards, warning that inadequate reforms could lock the country—and the continent—into decades of professional stagnation.
Why This Matters
• Professional mobility: Midwives trained in countries like Croatia or Greece may find their skills inadequate to work in Germany or Sweden under current regulations, limiting career opportunities.
• Outdated standards: The EU directive governing midwifery qualifications has remained substantially unchanged since 1980—predating modern reproductive health research by 46 years.
• Portugal workforce impact: The Portuguese Association of Obstetric Nurses (APEO) and university professors are among signatories demanding stronger reforms to support autonomous practice for maternal health specialists.
• National proposals: The Portuguese Nursing Order has submitted plans to the Health Ministry for autonomous monitoring of low-risk pregnancies by specialized maternal health nurses.
The 46-Year Regulatory Gap
Directive 2005/36/EC establishes minimum training standards that enable automatic recognition of professional qualifications across the European Economic Area. But the obstetrics provisions within that framework trace back to a 1980 text that experts say no longer reflects contemporary practice, scientific evidence, or what midwives actually do in 2026.
The International Confederation of Midwives coordinated the open letter delivered to Brussels this month, arguing that preliminary proposals from the European Commission lack alignment with current international standards. The revision process began in 2024—marking the first substantial review in over two decades—but signatories warn the draft changes amount to "cosmetic" adjustments rather than the transformational update the sector requires.
"This text no longer reflects what midwives do, the services that scientific evidence shows they provide best, or what the international community recognizes as the standard for high-quality sexual, reproductive, maternal, neonatal, and adolescent health care," the letter states.
Portugal's Push for Autonomous Practice
Within Portugal, the regulatory debate carries immediate implications for how maternal healthcare is delivered. The Ordem dos Enfermeiros (Nursing Order) has formally proposed that specialized maternal and obstetric health nurses (EESMO) be authorized to autonomously monitor and supervise low-risk pregnancies—a scope of practice expansion that hinges partly on how EU-level standards evolve.
Portuguese universities and the APEO joined the European advocacy effort, concerned that weak EU standards will function as a ceiling rather than a floor, constraining professional development and limiting what highly trained specialists can offer patients.
The current directive requires a minimum of 4,600 hours of combined theoretical and clinical training, with at least one-third devoted to clinical practice. By contrast, the International Confederation of Midwives recommends at least 40% theory and 50% clinical practice—a ratio designed to ensure competency in the full range of modern obstetric care, from routine antenatal monitoring to emergency intervention and postnatal support.
The Mobility Penalty
The regulatory gap creates practical barriers for professionals seeking to move between member states. A midwife trained in Croatia or Greece under the minimum EU standard may discover her qualifications are insufficient for positions in Germany, Sweden, or other countries with more rigorous domestic requirements. This discrepancy undermines the directive's original purpose: to facilitate free movement of qualified health professionals across the union.
"Several European countries apply the current directive as if it were a maximum standard instead of a minimum, limiting the mobility and professional development of professionals in this area," the open letter notes.
The Portugal context adds another layer of complexity. Domestically, the profession is often described as a nursing specialty—Enfermeiro Especialista em Saúde Materna e Obstétrica—which can obscure recognition of midwifery as a distinct, autonomous discipline. This nomenclature may complicate how Portuguese-trained specialists are perceived and accepted in other EU jurisdictions, even when their training meets or exceeds international benchmarks.
What the Global Standards Require
The World Health Organization and the International Confederation of Midwives jointly promote a framework emphasizing autonomous, evidence-based practice. Their guidelines call for curricula grounded in essential competencies, continuous quality improvement, and preparation for midwives to serve as primary care providers throughout pregnancy, birth, and postpartum periods.
WHO recommendations specifically endorse midwife-led models of care, which research shows improve outcomes, increase patient satisfaction, and reduce unnecessary medical interventions during childbirth. These models depend on practitioners trained to the full scope of contemporary obstetric practice—not the limited remit defined in a 1980 regulatory text.
The European Commission's draft update has been shared with EU and EEA member states for consultation. Advocacy groups are pressing for revisions that fully align the directive with ICM Global Standards and WHO guidance, arguing that anything short of that benchmark will weaken Europe's position as a global leader in maternal health.
Implications for Health System Resilience
Signatories to the open letter emphasize that strong midwifery regulation contributes directly to health system resilience, particularly during crises. The COVID-19 pandemic underscored the value of skilled, autonomous practitioners who could maintain continuity of care when hospital capacity was strained.
Advocates want the updated directive explicitly linked to the EU's Global Health Strategy, positioning robust obstetric training as a strategic asset rather than an administrative formality. They argue that elevating professional standards will reduce maternal and neonatal mortality, address health inequities, and prepare the workforce to respond to demographic and epidemiological shifts.
The Window for Change
Although the revision process began in 2024 and an external consultancy report was published in mid-2025, the update has not been prioritized on the Commission's 2026 agenda. Advocacy efforts are now focused on securing inclusion in the 2027 work program.
The stakes are high for Portugal and its European counterparts. If the directive is adopted in its current form, the result could be another generation of regulatory inertia—locking in standards that fail to reflect modern science, limit professional mobility, and constrain the contributions that highly trained maternal health specialists can make to public health.
"This update is the moment to change that, but only if the update is substantial," the open letter concludes.
For Portuguese health professionals, the outcome will determine not only career mobility across the union but also the scope and autonomy of maternal care practice at home. The Portuguese Nursing Order's proposal for autonomous low-risk pregnancy monitoring represents the kind of service model that modern standards could support—or that outdated regulations could continue to block.
