Maternity Care in the Context of Demographic Decline: Lessons From Greece for Europe

Across Europe, maternity systems are increasingly challenged by demographic decline, rising medicalization, and evolving expectations surrounding childbirth. Greece represents a particularly informative case. Despite a substantial reduction in annual births, the country continues to sustain one of the highest physician densities in Europe, with a large obstetric specialist workforce alongside a persistent shortage of midwives. This structural imbalance coincides with exceptionally high cesarean section (CS) rates. As mode-of-delivery data were unavailable before 2018 and substantially incomplete between 2018 and 2020, the most reliable assessment is limited to the period 2021–2024. Throughout this period, CS rates remained elevated throughout this period, ranging from 60.5% to 62.1% of live births, with the peak plateauing across 2023 and 2024 at roughly 62.1%. Considering national vital statistics, health workforce data, and comparative European indicators, this article presents a policy-oriented ecological analysis of maternity care in Greece. It briefly explores the interrelationship between workforce composition, medicolegal pressures, maternal demographic change, and patterns of obstetric intervention. Although Greek obstetricians report a strong personal preference for vaginal birth, clinical practice remains predominantly interventionist. The sustained predominance of CS appears to reflect a multifactorial etiology, encompassing defensive medicine, advanced maternal age, increasing recourse to assisted reproductive technologies (ART), insufficient training in operative vaginal delivery, maternal request shaped by counselling practices and risk perceptions, and the geographical concentration of high-risk pregnancies. Collectively, these features are compatible with, although not sufficient to demonstrate, supplier-induced demand operating within a physician-led maternity system in which midwife-led care remains insufficiently integrated. As a policy-oriented ecological analysis, this study identifies population-level associations and generates system-level hypotheses; however, it cannot establish causal relationships or determine, at the individual level whether a CS was medically indicated or potentially discretionary. Importantly, population-level outcomes are not clearly superior despite high intensity of obstetric intervention. In 2024, the perinatal mortality in Greece reached 8.2 per 1000 births, exceeding that reported in many Western European countries, although interpretation is limited by changes in registration criteria and maternal risk profile. Infant mortality remained close to the European Union (EU) average. Greece therefore illustrates a potential misalignment between service capacity, the model of care, and demographic need. This case has broader implications for European health systems, particularly in Southern Europe, and supports reforms in midwife-led care, professional training, medicolegal frameworks, and workforce planning.