BACKGROUND

Since February 24, 2022, the beginning of Russia’s invasion of Ukraine, more than 10.1 million refugees from Ukraine have crossed the Polish-Ukrainian border (Straż Graniczna, 2023). During the first two months after the outbreak of war, most of the refugees were women and children, some pregnant. The exact number of pregnant war refugee women is difficult to determine. According to the United Nations Population Fund (2022), an estimated 265,000 Ukrainian women were pregnant when the war broke out, and 80,000 women were estimated to give birth in the following three months. In 2022, 4,500 Ukrainian infants were born in Poland after February 24 (National Health Fund data for 2022). Although for most European citizens, the date of the outbreak of war is 24.02.2022, the war in Ukraine started in 2014. Ukrainians were coming to Poland also before February 24, 2022. The first wave of refugees came to Poland before the end of April 2022 (over 3 million), and the intensification of war-related fear also among Polish people (63.0% of Poles were afraid of war with Russia and it was their main concern; CBOS, 2022) was an exceptional situation and a challenge both for the Polish health care system, the health care workers and Polish citizens.

Experience of war is a risk factor for adverse, negative outcomes in pregnancy and after childbirth (Arnetz et al., 2013; Fatušić et al., 2005). It can result in premature birth and low birth weight, which is also observed in a population exposed to armed conflict (Davis & Sandman, 2010; Fatušić et al., 2005; Keasley et al., 2017). However, the rate of preterm births, stillbirths and miscarriages depends on direct exposure to conflict. For example, the adverse outcomes are often related to exposure to chemicals, radiation, exhaust fumes, contaminated water, or food during wartime (Arnetz et al., 2013; Signorello et al., 2010). Maternal mental health is also at additional risk. The perinatal period (from pregnancy to 1 year after childbirth) is a vulnerable time for the onset and recurrence of mental disorders, with perinatal depression, anxiety disorders, and posttraumatic stress disorder (PTSD) as the leading diagnoses. According to pre-COVID-19 pandemic data, it was estimated that 1 in 5 women would develop a perinatal mental disorder (Andersen et al., 2012; Fawcett et al., 2019; Hahn-Holbrook et al., 2018; Shorey et al., 2018). Also, the stress that a pregnant woman is exposed to, related to adaptation difficulties, stresses of daily life and other stressors, can reverse the cognitive assessment of the situation faced by the pregnant woman and complicate the adaptation process. For example, the tendency to perceive adverse events as uncontrollable is associated with an increased risk of perinatal depression (Ilska & Przybyła-Basista, 2014; Koss et al., 2014). The experience of war or forced refuge is undoubtedly associated with the experience of severe stress, anxiety and destabilisation, which can result in various negative consequences. Primarily, a risk factor in the group of pregnant and postpartum women from Ukraine is the experience of forced migration itself. A meta-analysis of 40 studies (N = 10,123) found that one-third of refugee women from low- and middle-income countries suffered perinatal depression (Fellmeth et al., 2018). A systematic review found a higher incidence of postnatal depression in migrant women, with rates 1.5-2 times higher than those of the general population (Falah-Hassani et al., 2015). According to clinicians working with the refugee population, a group of pregnant women and new mothers is an especially vulnerable group of the migrant population “in a precarious situation in a foreign country, when the sense of inner homelessness can quickly develop (which triggers the sense of homelessness), the capacity for empathy and intuitive parenting can be weakened” (Utari-Witt & Walter, 2021, p. 58). Studies conducted in war-affected Syria indicate a high percentage of women scoring higher on the postpartum depression scale (28.2%; Roumieh et al., 2019).

Supporting and protecting the mental health of refugee mothers also protects infant mental health. Genetics and environment influence brain development during gestation, so high neuroplasticity makes the brain particularly susceptible to environmental exposure to ‘nonoptimal’ levels of maternal distress (Monk et al., 2013). Stress during pregnancy has been related to poorer infant regulation (Fuller et al., 2018; Huizink et al., 2002), more negative affect (Davis et al., 2004; Graham et al., 2019), and corollary neural disruptions in early life (Demir-Lira et al., 2016).

According to Punamäki et al. (2018), pregnant and postpartum women living in the Gaza territory during the times of the Gaza War experienced not only the deterioration of mental health – increased PTSD symptoms, depression, anxiety, dissociative states, pregnancy complications – but also their children were more likely to be born prematurely. The infant’s psychomotor and language development was delayed. Maternal mental health during pregnancy and postpartum mediated the negative impact of war trauma on the child’s psychomotor and language development at 12 months. These authors’ previous study also showed that the mother’s ability to establish a strong bond with her unborn child, despite the stress experienced, is associated with more optimal sensorimotor and language development (Punamäki et al., 2017).

The abovementioned reports apply to non-Western societies. Therefore, when analysing these data, it is essential to keep in mind that they may not explicitly translate into characteristics of Ukrainian and also that things might be different in European cultures. However, given the lack of research on the importance of the war for the functioning of individuals in Western societies, it is worth paying attention to these studies to understand the possible outcomes better.

Working with people who experience the war trauma poses the question of what a normal reaction to grief, terror, and violence is. The international classifications of disorders – International Classification of Disease (ICD-11; WHO, 2018) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) – can help us to think about the difference between acute stress reaction (ASR), acute stress disorder and PTSD and possible ways of treatment. As described in ICD-11, an ASR is a “normal reaction, given the severity of the stressor, of an extremely threatening or horrifying nature”, “a natural disruption in functioning in the midst of extreme stress that should not be medicalised”. These reactions can range from autonomic to cognitive signs of anxiety, such as disorientation, non-responsiveness, or hyperalertness. The individual may be in a stupor or engage in overactivity. Regardless, these reactions are expected to subside within a few days after the event or following removal from the threatening situation. Acute stress disorder described in DSM-5 is characterised by intrusion symptoms, negative mood, dissociation, avoidance, and arousal, with symptoms defined as beginning after exposure to a traumatic stressor and lasting for at least three days and not longer than a month. PTSD may be diagnosed for individuals reporting similar symptoms from four clusters (intrusion symptoms, avoidance, negative alterations in cognition and mood, and alterations in arousal and reactivity) lasting more than a month and leading to distress or functional impairment. The person may reexperience the traumatic event in a distressing way during nightmares, flashbacks, and intrusive recollections of the event. They can also avoid situations that are similar to the trauma and present a numbing of general affective responsiveness. Symptoms of increased arousal, such as sleep disturbance, irritability and difficulty concentrating, are also part of the stress reactions (Ryding et al., 1997). The war in Ukraine is a lasting stressor. The relatives of refugees are endangered, and their houses and cities are destroyed – the exposure, even if not direct, is chronic. It is also possible that a pregnant woman who has not been directly exposed to an armed conflict, and was living in Poland before February 2022, may be more traumatised than a mother hiding from shelling (Chrzan-Dętkoś et al., 2022). The fear concerning relatives who stayed in Ukraine/joined the army, fear regarding the future of the country of origin, and watching the news of one’s country being destroyed could also be understood as criterion A of PTSD: reaction to the threat for relatives (Chrzan-Dętkoś et al., 2022). This shows that the experience of stress and its consequences can be very complex and require special attention from the environment, including medical personnel.

After the outbreak of war, the authors, as coordinators of the postpartum depression prevention programme, collaborating with 37 primary care health centres, had many inquiries from midwives focusing on what a normal grief reaction is and what a red flag signaling a potential problem is. The questions from midwives described the following typical situations: a new mother does not touch her newborn baby, and she is watching her mobile phone and talking in Ukrainian on the phone; the new mother is crying while watching TV and talking on the phone – however, she seems to care for her baby. Are these acute stress reactions or acute stress disorders? Shall we only accompany and support the mothers or refer them?

These examples show that the role of midwives in health care is crucial: midwives are often the first health care professionals with whom women have contact. Midwives face challenges of giving emotional support, accompanying and co-sharing their pain, identifying the most vulnerable women, and assisting in more complicated pregnancy and childbirth outcomes. Poland, compared to other European countries, is a culturally homogeneous country. The war in Ukraine challenges midwives to care for women from different cultural backgrounds. However, we do not know what would be the most challenging cultural differences – if such exist – between Polish and Ukrainian patients. These two cultures are perceived as close, sharing similar language, religion and values. However, getting to know midwives’ perspectives and daily observations is essential. Some data show that women from different cultural backgrounds may differ in describing their problems or accessing help. For example, migrant women from non-western cultures may describe somatic rather than psychological symptoms (Jadhav, 2000; Templeton et al., 2003) or may have symptoms of postpartum depression, but the concept may not exist within their language or culture (Jain & Levy, 2013). Although all women rated childbirth pain as very high, the women from the Middle East (women whose mothers were born in Asia or North Africa) compared with women from a Western background (women whose mothers were born in Europe, the United States, or one of the other English-speaking countries) gave higher ratings of pain. They showed more pain behaviour (Weisenberg & Caspi, 1989) – such information may be helpful for midwives.

PARTICIPANTS AND PROCEDURE

The primary objective of this study was to conduct a qualitative analysis of midwives’ experiences of maternity care for females from Ukraine after the outbreak of war in the context of any cultural differences and possible degrees of war traumatisation. Additionally, the study aimed to identify the main challenges of working with potentially vulnerable Ukrainians after the outbreak of war and the need for support for patients and midwives. The present study is part of a larger international project concerning the perinatal mental health of refugee women and represents the result of exploratory activities. In our study, we sought to answer the following questions:

RESULTS

A detailed analysis of the collected material was conducted. Quantitative data on the degree of traumatisation were counted using statistical analysis methods in the SPSS program. After being transcribed in advance, the qualitative data were analysed thematically in detail by two expert judges. First of all, judges got acquainted with all the collected material. In the beginning, the focus was on analysing points of commonality in the responses of individual midwives. Next, the observed differences were analysed to assess the degree of divergence. In the next step, the focus was on assessing the relevance of the midwives’ statements to the subject matter analysed to obtain answers to the research questions posed. The results are presented below.

DISCUSSION

This small study on the midwives’ experiences aimed to examine their reflections and challenges in working with Ukrainian patients after the outbreak of war through in-depth interviews. We asked how midwives assessed the patients and themselves regarding the traumatic stress overload, cultural differences, and their need for help and assistance at work.

Midwives feel burdened with the war. They show empathy, support and increased commitment but feel left alone, unprepared by the system or the employer to care for a new group of patients. Of course, the war was so sudden and unexpected that there was no time for preparation. However, our earlier study (Chrzan-Dętkoś & Walczak-Kozłowska, 2021b;) showed that in general, the preparation of medical staff for the management of patients with mental health issues, including earlier trauma, is relatively low. Despite the significant positive changes in perinatal care in Poland, initiated in 1994 with the “Rodzić po ludzku” campaign, there are still many women who experience feelings of incomprehension, harm and violence from medical personnel during childbirth, which shows the frequent lack of adequate preparation to build a relationship with the patient based on trust and empathy (Adamska-Sala et al., 2018). However, it is worth emphasising that interested midwives could take part in a series of webinars focused on possible cultural differences and work with traumatised patients, which were prepared by specialists and shared on social media for free. Midwives and other health care professionals can benefit from recommendations developed from the literature review for working with women in the perinatal period who have experienced the war (for more see Chrzan-Dętkoś et al., 2022). The vital protective elements were identified, which may alleviate the negative impact of war and refugee status experiences.

Nevertheless, participating midwives reported ease of establishing contact with Ukraine patients after the outbreak of war, the willingness to build relationships and provide support. All the surveyed midwives emphasised that they were willing to offer their patients themselves by showing empathy, holding their hands, trying to recognise the patients’ needs and understanding the language. The midwives felt that they could support their patients, whether the Ukrainian women chose to disclose their situation or not. It is probably a protective factor for mental health of Ukrainian patients after the outbreak of war (Bielska & Czerkawski, 2016), but it can be an additional burden for midwives, for whom work even under standard conditions is often a stressor (Jankowiak et al., 2011). The additional burden of the patient’s complex emotions, midwives’ anxiety about the war and the common anxiety observed in Poland concerning the war with Russia (63.0% of Poles; CBOS, 2022), and the pressure to help the patient in the best way possible can consequently lead to a state of compassion fatigue or vicarious traumatisation. The latter is a phenomenon that occurs in contact with trauma survivors, whose severe stress or crisis exceeds the coping strategies of the healthcare provider and indirectly leads to various mental abnormalities (Gawrych, 2022). This phenomenon was observed among medical workers during the COVID-19 pandemic (Gawrych, 2022). In the subjective opinion of midwives, the average result of the emotional burden of war was slightly higher in them than in patients. An explanation for this phenomenon may be the heavy emotional burden on midwives, which can cause burnout, as well as evoking traumatic and harrowing memories of the war, which are often still vivid in Polish people. In addition, the situation when midwives who care for the patient try to contain their difficult emotions without any extra support from the employers can be demanding and difficult. Only one of our respondents had basic information about the consequences of war trauma and stress during pregnancy for the course of childbirth and puerperium. This shows that midwives may feel unprepared to respond to the needs of war-experienced patients while feeling a strong need to make their responses as helpful as possible to patients.

Participating midwives declared that they show compassion and acknowledge a history of trauma and current fear. ‘Acknowledging’ or ‘validating’ someone’s painful experiences can be healing as a vital intervention element and may help foster positive relationships. Embracing and storing a patient’s negative emotions and trying to mentalise them and show that they can be overcome can be an essential factor in building relationships in maternity care (Bronowski, 2017). As the survey shows, women describe expectations of midwives in terms of building a trusting relationship with them (Berg et al., 1996). Communicating empathetically is an integral part of supporting a woman during pregnancy and childbirth (Baranowska & Doroszewska, 2018; Chrzan-Dętkoś & Walczak-Kozłowska, 2021a). In the context of the traumatic and stressful experience, empathy and trust may be even more critical. As research conducted during the COVID-19 pandemic (also a highly stressful situation for pregnant women) shows, the experience of a crisis can be associated with an increased need for extra caution and mental health support for postpartum women (Chrzan-Dętkoś et al., 2021a). Our respondents seem to try to do it in their work by being more accessible, showing empathy and understanding, and non-verbal communication. However, combined with emotional involvement and the emphasised lack of employer support, the high score of traumatic stress, indicating our respondents’ risk of compassion fatigue, vicarious trauma and burnout, is not surprising. Research shows that dissatisfaction with work is related to exposure to chronic stress and anxiety situations (Leinweber et al., 2017). Based on the interviews, we can hypothesise that contact with traumatised patients is emotionally demanding. Participating midwives, like many others in Poland, work in a few places, often exceeding the required 40 hours of workweek time, and may burden their resources. Midwives’ role is to contain the intense feelings of their patients: they help them organise ambivalent feelings of love and anxiety, stress and guilt for being safe while their relatives are still in danger. They risk being vicariously traumatised by approaching war-experienced patients with greater openness and empathy. In addition, the experience of World War II and the devastation associated with it is still vivid in Poland. The war across the eastern border could reactivate intergenerational fears. According to international studies, in crises, front-line healthcare staff who are directly involved with trauma-affected patients are especially vulnerable to stress and mental health problems (Holmes et al., 2020).

The study shows the necessity to introduce actions aimed at preventing vicarious traumatisation and compassion fatigue, which already affect the representatives of this profession. Our respondents tried to create a safe environment in maternity wards and primary care health centres by establishing trust-based relationships with patients, showing compassion, and providing more attention and understanding. This can prevent the adverse effects of the trauma for Ukraine patients after the outbreak of war or reduce its negative impact on the well-being of mothers and thus protect infants while significantly burdening midwives. The knowledge about trauma-informed care in the perinatal period must be higher among the participating midwives. This is not surprising, as this topic is not discussed during studies, and employers do not conduct such training (Chrzan-Dętkoś & Walczak-Kozłowska, 2021b). To minimise the negative psychological impact of the war, it is necessary to develop appropriate prevention strategies, as well as training and support programmes. It is extremely important to identify risk factors that may help detect groups at increased risk and develop adequate interventions. Also, the help with translation should be organised by the employer, not individual workers. A typical example of cultural awareness and sensitivity (caring) is, for example, offering print and electronic materials in the languages spoken by people accessing care and offering translation services. Visual cues within the hospital with information in the Ukrainian language could be a vital sign of support.

Moreover, it is necessary to introduce well-organised, systematic procedures and guidelines that will improve maternity care and work with Ukrainian patients. Another factor facilitating work with Ukrainian patients is their high assessment of maternity care, which they perceive as better organised than in Ukraine. Additionally, midwives see Ukrainian women as representatives of a similar culture, sharing similar values, making their work easier. Therefore, the differences observed by midwives are due to the different organisation of the medical system rather than cultural differences. However, our study shows that the issue of vaccinations may be a future problem. The WHO data show that, for example, only 42.0% of children received measles vaccination in 2016, with an improvement in 2019 to 85.0%. However, it is still below the expected rate of 95.0% (WHO, 2022).

CONCLUSIONS

In this short study, which is part of a larger project concerning the perinatal mental health of Ukrainian women after the outbreak of war, we would like to draw attention to the situation of medical personnel who report the need for additional psychological support for themselves while caring for Ukrainian patients. The experience of giving birth in forced exile may have negative consequences for the mother and child, and the war stress may even increase. However, the role of the midwife-mother relationship may mitigate the burden (Chrzan-Dętkoś et al., 2021b). This shows the enormous importance of prevention and the preparation of staff to work with women with refugee status or those who have trauma experience and who are in a double risk group: both due to the war-related experiences and a greater risk of perinatal complications re-influencing the mental state (Collins et al., 2011; Fellmeth et al., 2017). The more the medical staff feels prepared and supported in new challenges, the easier it will be to care for patients who have experienced many losses and stress.