# Ukrainian women's maternity care strategies in Poland after the outbreak of the full-scale war: Understanding unequal access to quality care

Social Science & Medicine, Volume 362, December 2024

## Maria Węgrzynowska

Department of Midwifery, Centre of Postgraduate Medical Education, Warsaw, Poland

## Nina Sahraoui

PRINTEMPS, CNRS, Université Versailles Saint Quentin en Yvelines, Paris Saclay University,
France

## Ilona Nenko

Department of Environmental Health, Faculty of Health Sciences, Jagiellonian University
Medical College, Krakow, Poland

## Beata Szlendak

Department of Midwifery, Centre of Postgraduate Medical Education, Warsaw, Poland

## Barbara Baranowska

Department of Midwifery, Centre of Postgraduate Medical Education, Warsaw, Poland

## Abstract

The outbreak of the full-scale war launched by Russia against Ukraine and, following it, significant migrations have not only increased the diversity of the Ukrainian migrant population in Poland, but also added to the complexity of their health needs and strategies. This study seeks to explore Ukrainian migrant women's experiences and practices related to the use of maternity care services. The article is based on fieldwork conducted between February and October 2023 and included 23 semi-structured interviews with Ukrainian migrant women who gave birth in Poland after February 24, 2022. To understand Ukrainian women's pathways to maternity care in Poland and unpack the differences in experiences within this group of migrants, we explore participants' healthcare strategies against the background of existing inequalities in access to quality care in Poland and Ukraine, in particular the division between private and public services. We consider the role of financial, social and cultural resources and distinguish for this purpose between three groups of permanent, circular and wartime migrants. We show the decisive role of economic resources, nonetheless in articulation with the creation and mobilisation of social networks and time spent in Poland, which play a role in shaping migrant women's capacity to access better maternity care.
# 1. Introduction

This study seeks to explore the experiences and practices of Ukrainian migrant women living in Poland related to the use of maternity care services. Since the outbreak of the full-scale war launched by Russia against Ukraine in February 2022, millions of Ukrainian people, mostly women and children, fled to Poland (Bloch et al., 2023). While pregnant migrant women fleeing war constitute a vulnerable group, the outbreak of the war also had an impact on healthcare practices of Ukrainians already living in Poland or engaged in circular migration. The arrival of Ukrainian citizens fleeing war not only increased the diversity of the Ukrainian migrant population in Poland, but it also added to the complexity of their health needs (Kismo"di and Pitchforth, 2022) and strategies, as those already established often bore the weight of being the safety net for those fleeing the war (Drąz'kiewicz et al., 2023).

Research showed that pregnant migrant and refugee women have poorer perinatal outcomes than the general population in the host country (Heslehurst et al., 2018; Sturrock et al., 2021; V"ais"anen et al., 2022). The differences may result from the vulnerable position migrant persons occupy in the host societies. This was found to be particularly true in case of individuals coming from countries with fewer economic resources (Heslehurst et al., 2018) and in specific contexts such as borderlands (Grotti et al., 2018). They experience numerous disadvantages compared to the non-migrant population, which may affect their health and healthcare practices, and the quality of care they receive. However, not all migrant persons are equally affected by the same disadvantages. There is a growing body of research exploring various barriers and facilitators that migrants encountered when accessing services (Ahmadinia et al., 2021; Czapka and Sagbakken, 2016; Fair et al., 2020). However, less attention was paid to the diversity within migrant populations, how migrants' different social positioning affected their patterns of access, and the quality of care in the context of larger inequalities in and across the host and home societies (Fedyuk, 2020; Lafleur and Romero, 2018; Shutes, 2016; Stan, 2015; Troccoli et al., 2022).

Social class, economic resources and social networks have been found to determine migrant persons' access to healthcare across borders, with transnational healthcare practices used to navigate healthcare inequalities (Lafleur and Romero, 2018; Levitas, 2020; Main, 2016; Stan, 2015; Troccoli et al., 2022). Thus, in our study, we consider the role of migrant women's social position, including their financial (e.g. ability to pay for private care), social (e.g. social connections) and cultural resources (e.g. knowledge of the language) in shaping their healthcare strategies. We examine how these dimensions matter for Ukrainian migrant women in Poland and distinguish for this purpose between three groups of permanent, circular and wartime migrants. We show the decisive role of economic resources, nonetheless in articulation with the

creation and mobilisation of social networks and time spent in Poland, which play a
role in shaping migrant women's capacity to access better maternity care.

## 2. Setting: Ukrainian migrants in Poland and access to maternity care in Ukraine and in Poland

Ukrainian citizens are the most numerous migrant group in Poland and has been steadily increasing over the last decade. Before February 2022, the number of Ukrainian citizens living in Poland was estimated at around 1.1–1.2 million (Duszczyk et al., 2023). In the months following the Russian invasion, around 2 million people from Ukraine sought protection in Poland (Bloch et al., 2023). The group mainly included women and children, as men between the ages of 18 and 60 were forbidden to leave Ukraine with just a few exceptions (Duszczyk et al., 2023). By the end of 2022, the number of Ukrainian citizens in Poland had been estimated at just above 2 million people, with about 950,000 having the temporary protection status (Duszczyk et al., 2023).

The Russian aggression on Ukraine was followed by unprecedented legislative solutions adopted at European and national levels to accompany the arrival of significant numbers of Ukrainian refugees. Ukrainian citizens (and their non-Ukrainian spouses) who entered Poland fleeing the war after February 24, 2022 were granted temporary protection (Ustawa z dnia 12 marca 2022 r. o pomocy obywatelom Ukrainy w związku z konfliktem zbrojnym na terytorium tego pan'stwa, 2022), in line with the EU first-time activation of its 2001 Temporary Protection Directive (TPD) on March 4, 2022. This gave Ukrainian citizens immediate (without the lengthy bureaucratic procedures as aimed by the TPD) and temporary access to the labour market and social and healthcare services, including access to publicly-funded maternity services with similar healthcare rights as available to Polish citizens. In 2022, a total of 13,787 women from Ukraine gave birth in Poland, which constituted around 4.5% of all births registered in the country – twice as many as a year before (our own calculations based on data provided by the Statistics Poland) (GUS, 2023).

The social mobilisation following the arrival of refugees was also unprecedented. In the first weeks after the invasion, about 70% of the Polish population declared being involved in some form of aid activities, including volunteering at reception centres, hosting refugees or providing financial support (Baszczak et al., 2022). Similarly, in many healthcare facilities, care providers were engaged in grassroots initiatives, such as making phrasebooks, bilingual leaflets or mobilizing their personal contacts (such as Russian or Ukrainian speaking acquaintances) to facilitate access to higher quality care for migrants (Biesiada et al., 2023; Nenko et al., 2024). However, the initial enthusiasm and people's willingness to help gradually wore off and some authors suggested that anti-Ukrainian sentiments were on the rise in Poland (Helak, 2022). This seems particularly alarming considering that the Polish healthcare services continue to lack the coherent and sustainable solutions facilitating the
provision of and access to quality care for migrant populations. This includes the lack of guidelines and training programmes for healthcare professionals on the provision of trauma and culturally informed care, lack of interpretation services or institutional support for healthcare personnel (Chrzan-Dętko's and Murawska, 2023; Nenko et al., 2024). These might leave numerous Ukrainian migrant women in a particularly vulnerable position of being labelled as “abusers” of the already overburdened social and healthcare systems.

Both in Poland and Ukraine, women are entitled to free, publiclyfunded maternity care (Kravchuk et al., 2020; Ustawa z dnia 27 sierpnia 2004 r. o ´świadczeniach opieki zdrowotnej finansowanych ze ´srodk´ow publicznych, 2004). However, access to quality maternity care is highly unequal in both countries and strongly dependent on means (Stepurko et al., 2013; Węgrzynowska, 2021). Generally, fee-for-service care offers faster access to specialist consultations, access to some services (such as some forms of prenatal genetic screening or lactation consultations) not financed from the public sources as well as, in some cases, higher quality care. Healthcare services in general, and maternity care in particular, enjoy a relatively poor reputation among women. In Poland, despite great improvements implemented over the last two decades, many women continued to experience mistreatment, including insufficient information, lack of privacy and nonchalant treatment (Baranowska et al., 2019). Moreover, Poland was reported to have one of the most medicalised maternity care services in Europe, with over half of pregnancies ending up with caesarean section (Biuletyn Statystyczny ministra zdrowia, 2021, 2021). In Ukraine, obstetric violence and poor quality care was recognized as a serious problem to be addressed (Chernysh et al., 2023; Kravchuk et al., 2020). The country has one of the highest maternal mortality rates in Europe and, although the rates have shown some signs of improvement over the last decade, they continue to stay far behind those in other European countries, including Poland (World Health Organization, 2023). The outbreak of the full-scale war in Ukraine in 2022 is likely to have a profound negative impact on the access and quality of maternity care in Ukraine (Krupelnytska and Morozova-Larina, 2023).

In both countries, building personal relationships with healthcare providers is perceived by women and their families as a way to overcome these shortcomings and ensure better care (Stepurko et al., 2013; Węgrzynowska, 2021). In Ukraine, these relationships are often built by informal payments that women are expected to make to the healthcare personnel in publicly-funded hospitals. It is a well-established and particularly prominent practice aimed at obtaining access to better maternity care (Stepurko et al., 2013, 2015). Research from a maternity hospital in Kiev showed that women presenting at the facility were categorized by the healthcare personnel by whether they had or had not made arrangements with a particular doctor to pay for care (Stepurko et al., 2013). The former were recognized as “private patients” and were more likely to receive more attentive care, while the latter could suffer suboptimal care while still being expected to make some form of informal payment to the staff.

In Poland, informal payments are far less popular (Stepurko et al., 2015) and, in
general, they are not expected by the personnel to provide better care. However, over
the last three decades, private maternity services have become a catalyst for building
personal relationships between women and care providers that may be transferred
to publicly-funded facilities where most women give birth (Węgrzynowska, 2021). Despite
being entitled to publicly-funded care, many women in Poland pay for private
prenatal services to build a stronger social position of “being someone’s private
patient” as opposed to being “someone simply from the street”, which increases
their chances of getting more attentive and better care (Węgrzynowska et al., 2023).
Thus, while the process of patient selection seems to be more formalized in Poland
than in Ukraine, it continues to operate in many publicly-funded facilities through
officially paid private care. In both countries, this strategy of ensuring better care
requires women to have social and economic resources, as well as cultural
competence and understanding of the nuanced ways healthcare provision is
structured.

3. Methodology

This study is part of a larger project that seeks to explore both the experiences and
practices of Ukrainian migrant women using maternity services and those of healthcare
professionals providing those services in Poland during the war in Ukraine. The
fieldwork was conducted between February and October 2023 and included semi-
structured interviews with Ukrainian migrant women who gave birth in Poland after
February 24, 2022, focus groups with maternity care providers (mainly midwives),
the analysis of secondary sources of information (such as information leaflets for
migrants, publications on maternity care for migrant women by the Polish Migration
Forum, or discussion in the online support groups for migrants or care providers), as
well as meetings and informal conversations with activists and representatives of aid
organizations working in the area of maternity care and migration.

This article is primarily based on 23 interviews with Ukrainian migrant women.
The interviews were conducted by the first author, who is a social anthropologist and
a midwife. We recruited participants mainly through social media support and
interest groups (the first author posted an online invitation after obtaining permission
from the group administrator), as well as our personal networks and the snowball
technique. It was quite common for the participants to refer other migrant women
to us. The interviews focused on the women's migration trajectories as well as their
patterns of access to healthcare in Poland and experiences with particular types of
maternity care. The interviews were conducted either in person (13 interviews) or
online (10 interviews), depending on the women's preferences and their place of
residence. The majority of the face-to-face interviews were held in public spaces,
such as local parks usually suggested by the participant. One of the women invited
the researcher to her home. Most participants lived in or around the capital city of
Warsaw. Five women lived in other cities in Poland and, at the time of the interview,
one had already moved to another country.

During the initial contact, the women were provided with plain language statements written in Ukrainian and Polish, concerning the aim of the study, participation requirements, the voluntary nature of the participation and confidentiality. The overwhelming majority of interviews were carried out in Polish. The women were offered a female interpreter to be present during the interview but only one woman requested it. The interviews were recorded and transcribed. Each interview lasted between 40 minutes to over an hour. At the stage of transcription, in case of any doubts regarding translation, an interpreter was contacted to translate the recording or provide transcriptions. All the names used in this study are pseudonyms.

We used reflexive thematic analysis informed by the contextualized approach to analyse data collected through semi-structured interviews (Braun and Clarke, 2006, 2021). We understand coding as “an organic and evolving process of noticing potentially relevant meaning in the dataset, and ultimately building a set of codes from which themes are developed” (Braun and Clarke, 2021). Boyatzis (1998: 11) identifies furthermore four stages for coding within thematic analysis: “1. Sensing themes – that is, recognizing the codable moment. 2. Doing it reliably – that is, recognizing the codable moment and encoding it consistently. 3. Developing codes, and 4. Interpreting the information and themes in the context of a theory or conceptual framework – that is, contributing to the development of knowledge.” Conducting thematic analysis supposes to repeat these steps several times to complete the process rigorously. ‘Recognizing the codable moment’ emerges for instance at different points in time, ‘Developing codes’ means that the coding tree can be revised along the way, and ‘encoding it consistently’ supposes several phases of coding to ensure that all transcripts are covered by the final coding tree. Coding was conducted by the first author and specific codes were discussed by two authors (M.W and N.S) in the spirit of Boyatzis’ methodology to allow for the development of analytical interpretations during coding.

We identified three main groups of female Ukrainian migrants: permanent migrants, circular migrants and wartime migrants. Ten out of the 23 women we interviewed were permanent migrants who had come to Poland, often with their partners, before 2022 to seek better employment opportunities. The length of their stay in Poland differed between 10 years and two years before the outbreak of the war. At the time of the interview, they were all well-settled and declared they had secured a form of income and employment-based access to social and healthcare services, either through their own employment or their partners’. Some of the women experienced periods of irregularity and worked undocumented jobs at some point while living in Poland. Most of the women in this group spoke fluent Polish and had some experience using healthcare, mostly GP services, prior to using maternity services. In addition, some had private health insurance either as part of their employment benefit or paid by themselves. They all lived with their partners who, except for one couple, were Ukrainian migrants. Many of the permanent migrants at the time of the interview also lived with their family members such as parents or in-
laws who escaped Ukraine after the outbreak of the full-scale war.

The second group included circular migrants, who, similarly to permanent migrants, first had come to Poland prior to 2022, but unlike permanent migrants, they had regularly travelled from Ukraine to Poland for a longer or shorter period (from several weeks to several months) to work. They usually engaged in undocumented jobs, such as cleaners or carers, to generate income for their family budgets in Ukraine. These women had limited access to publicly-funded social and healthcare services prior to the war and relied mostly on healthcare services in Ukraine. All three circular migrants we interviewed were in Poland on the February 24, 2022. In the weeks following the invasion, they travelled to Ukraine and back to Poland, and received the temporary protection status. This enabled them to obtain access to publicly-funded maternity care.

The third group encompassed migrants who came to Poland in the first weeks after the outbreak of the full-scale war in Ukraine and had no history or intention of migrating to Poland previously. This group was particularly heterogeneous, including women from diverse social, economic and cultural backgrounds, coming from regions of Ukraine differently affected by the war, having different personal experiences of the war, access to social support networks in Poland and plans for the future. They all arrived in Poland at various stages of pregnancy with two participants late in their third trimester. Many of them experienced temporary separation from their partners who were not able to initially leave Ukraine due to being of military age. However, at the time of the interview, most women declared they had been reunited with their partners who either crossed the border semi-illegally or were granted permission as a parent of three or more children or a child with disability. Wartime migrants varied regarding the level of proficiency in Polish, but due to the similarity of the languages, many had passive understanding of spoken Polish.
4. Ukrainian women's strategies of access to quality maternity care in Poland

Although through different pathways (employment-based insurance, the temporary protection status obtained by travelling to and back from Ukraine and entering Poland after the outbreak of the full-scale war), all migrant women we interviewed had a formal access to publicly-funded maternity services in Poland. They declared no major formal difficulties in registering for their publicly-funded prenatal check-ups or inpatient care. None of the women were billed for the care they received at publicly-funded facilities. However, many of them complained about long waiting times, particularly as regards specialist consultations. Most women were satisfied, especially with the intrapartum care they received. However, they all mentioned experiencing several informal barriers, including the fear of being discriminated, limited understanding of how healthcare services worked in Poland and the language barrier.

The permanent and circular migrants constituted a group which particularly emphasised having experienced rising hostility and anti-immigrant attitudes following the increased number of Ukrainian citizens arriving in Poland after the outbreak of the war. Some women declared that they had been confronted with open forms of discrimination, such as rude comments from their maternity care providers or experienced more subtle instances of discrimination, such as being avoided by midwives in the postpartum wards.

Women also expressed frustration associated with misunderstanding regarding the way healthcare services worked. This was particularly true for migrants who arrived after the outbreak of the war and circular migrants who had little or no experience using Polish healthcare services. As they emphasised, they often received little explanation on where and when to go to receive maternity care, how to find a paediatrician and where to seek emergency care. Such misunderstandings were often amplified by the language barrier. Interpreters were rarely available – only one of the participants used an interpreter who volunteered at the hospital. The remaining women with limited language proficiency relied on translation apps, their friends or family members who translated for them, or simply on the similarity of the languages.

All women expressed a desire for attentive care and engaged in various strategies to minimise risks of being mistreated and to ensure better care for themselves and their babies. We identified three main strategies that women engaged in while navigating the Polish (and in some cases Ukrainian) maternity care services: accessing private care, making connections with Ukrainian or Russian-speaking healthcare professionals and engaging in transnational healthcare practices. Below we discuss these micro-level strategies, considering the impact of macrolevel structural factors (the outbreak of the war, formal access to healthcare services, inequalities within the Polish healthcare) and the meso-level of social networks in shaping these strategies and their effectiveness. Although they are discussed separately, these strategies do not
constitute distinctive pathways. Indeed, numerous women combined these strategies
in their attempts to achieve the best outcomes, mobilizing their economic resources
and social networks to pay for private care, access certain physicians or engage in
transnational healthcare.

4.1. "Taking a typical Polish pathway" – accessing private services to ensure more attentive care

Although most of the migrant women we talked to accessed private maternity
services at some point during their pregnancy in Poland, it was mostly the better off
and more settled migrant women who relied on private prenatal care to access more
attentive care.

Natalia, who came to Poland in 2015 and worked as a receptionist for a large
company in Warsaw explained that she had never seriously considered attending
publicly-funded services as she worried about long waiting times and inattentive care.
She reached out to her Polish colleagues to investigate her care options and decided
to sign up to a private clinic:

"I read the reviews, I spoke to my Polish colleagues and they told me I need to go private because this [publicly-funded care] takes more time and some doctors may not treat me seriously. It was said like that: they may not treat you seriously. And this was not because I am Ukrainian, but because this is how it is, the whole care system in Poland." (I2,
arrived in Poland in 2015 with her partner)

As Natalia stressed, she feared the lack of attention from publicly-funded care,
which was not only due to her position as a migrant, but also due to the division
between the public and private care in the Polish healthcare services that could be
further exacerbated by Natalia's position as a migrant. Thus, she decided to sign up
to the private clinic recommended to her, where she hoped to receive attentive care.

In contrast, circular migrants and those who arrived in Poland after the outbreak of
the war used private services occasionally, usually as backup in case of problems
registering for a visit in a timely manner or when they searched for a second opinion.
Victoria, a circular migrant who received most of her prenatal care in a publicly-
funded outpatient clinic in the suburban area of Warsaw, travelled once for a fee-
for-service consultation in a private clinic in Warsaw. Although she had no major
complaints about her publicly-funded doctor except him being taciturn, she decided
to seek a second opinion in a private clinic. However, she never planned to continue
the private visits and considered it to be a one-off.

"I went [for a private consultation] once before giving birth because I decided I wanted to see whether everything was fine. My doctor,

[publicly-funded] when doing an ultrasound scan, would say very little to me. He thought I did not understand. Whenever I asked, he also understood me very poorly. If something was wrong, I assumed he would tell me but I just wanted to make sure all was fine." (I15, a circular migrant, partner in Poland)
Lena, a primary school teacher from eastern Ukraine who arrived in Poland after the outbreak of the war with her two young children and pregnant with the third one, attended two private consultations. After her arrival, through an aid organisation, Lena was put in contact with a Polish family who helped her organise accommodation and visits in a publicly-funded outpatient clinic. However, when Lena waited for a publicly-funded appointment, the family arranged two private obstetric consultations for her with a doctor they attended when pregnant with their own child. Lena did not have the money to pay for the consultations and suspected that either the family paid for them or the consultations were provided by the doctor as a favour to the family.

“I met the family [who volunteered to offer support]. They took care of me, and this lady [from this family] signed me up to her doctor with whom she had given birth (...). We went for an ultrasound scan and I have a nice, first picture of my son from there.” (I8, arrived in Poland after the outbreak of the full-scale war, joined by her partner after she had given birth to their third child)

Similarly to Viktoria, Lena had never considered regular visits in a private clinic. It was too expensive to her and she did not want to be a burden on the family who helped her. Lena considered those two consultations to be a bonus, during which she made sure everything was fine with her pregnancy and received nicely framed ultrasound pictures of her baby.

### 4.2. “Having someone who understands me” – making connections with Ukrainian personnel in Poland in private and public settings

Many of the migrant women we interviewed searched for Ukrainian or Russian-speaking physicians to attend for their prenatal consultations. Over the last decade, private outpatient clinics run by Ukrainian and Russian-speaking physicians have started to operate in several large cities in Poland. They are registered facilities within the Polish healthcare system and provide private fee-for-service care. In practice, they mainly cater to Ukrainian and Russian-speaking migrants living in Poland. They provide private consultations with a wide range of specialists, including “prenatal care packages” offering several screening and obstetric consultations that women may purchase.

Migrant women who used such services for their prenatal care explained that they did so mainly due to cultural familiarity and the absence of the language barrier when talking to Ukrainian physicians. Ukrainian healthcare personnel also were ‘cultural bridge-builders’ (Næss, 2019) and guided women through the Polish healthcare services.

Natalia, who came to Poland in 2015, explained that she decided to pay out of pocket for prenatal care with a Russian-speaking physician because she worried about miscommunication. Although fluent in Polish, she still worried she might be unable to fully explain herself and understand the doctor in case she went to a Polish-speaking physician. She also wanted to avoid any possible discrimination
based on her nationality. She believed that the outbreak of the war and the increased migration from Ukraine to Poland put Ukrainian citizens at a higher risk of receiving poorer care and experiencing rude comments:

“I went to a Russian-speaking doctor because this was my first pregnancy and I did not want not to understand the doctor. (...) In everyday life, I speak Polish normally but sometimes I just don't know how to say things. (...) So I decided to go privately to a Russian-speaking doctor because I was afraid of miscommunication. (...) And also, every time I went to the doctor [in Poland] they would ask me whether I was a refugee. And I think the care was ... not so good. So when I got pregnant I decided not to go to publicly-funded but to private clinics.” (I2, arrived in Poland in 2015 with her partner)

Although private consultations constituted a considerable burden on Natalia's family budget, she believed she made a good decision as she felt very well cared for. She believed her Ukrainian physician was very competent and provided her with high-quality care. Moreover, she received information about how Polish maternity services worked and was advised which hospital to choose to give birth in.

Women with no financial resources to pay for private consultations engaged in a variety of strategies to make connections with Ukrainian personnel and to maximize their chances of being “someone’s patient” and having someone who could advocate for them within the Polish healthcare system. Such strategies included searching for health providers collaborating with aid organizations, choosing a hospital where some healthcare personnel had Ukrainian background or making connections with Ukrainian non-medical personnel working at the hospital. Anna, a shop assistant from south-east Ukraine who arrived in Poland after the outbreak of the full-scale war, read on social media about a Ukrainian midwife working at one of the publicly-funded outpatient clinics in Warsaw. Anna did not speak Polish and had considerable problems understanding the language, so she chose this particular clinic. She explained that it gave her hope there would be someone to help with communication and support her in case of any problems. However, due to Anna's health complications, she was transferred to another clinic with no Ukrainian-speaking doctors or midwives. Although she was happy with the care she received there, she found it difficult to communicate with her physician. No interpreting services were available in the hospital and Anna relied on online translation apps. When she could not understand screening results, Anna used social media to contact the above mentioned Ukrainian midwife who worked at one of the publicly-funded clinics in Warsaw and to ask for help.

“I found her [a midwife from Ukraine] on Facebook and sent her a private message to show her my [screening] result and she messaged me back to say that all is fine. It was good because I was nervous something was wrong, and I did not understand what the doctor said.” (I10, arrived in Poland after the outbreak of the war with her partner)

Viktoria, a circular migrant, despite being fairly fluent in Polish, experienced several misunderstandings during her hospital stay, including rules concerning the visiting hours. After being told by one of the midwives that her partner was not
allowed to visit her because it was outside the visiting hours, Viktoria reached out to one of the cleaning staff members who was from Ukraine:

“And I thought: she [the midwife] does not want to hand me the baby [from the crib], I cannot stand up, she [the midwife] does not want to let my husband in and tells me to wait until 2 pm. But there was a cleaning lady there [at the hospital] who was also Ukrainian and had worked there for many years. And she told me to let her know if I needed anything. So when the midwife saw me crying and asked what was going on, I told her to get me this cleaning lady. So they [the midwives] told her [the cleaning lady], and she came to my room and I told her everything: that my husband is waiting and they would not let him in. And 5 minutes later they would let him in.” (I15, a circular migrant, partner in Poland)

Viktoria believed her partner was allowed to the ward because she was no longer “someone simply from the street” but gained a stronger social position due to the cleaner's advocacy. However, this position was temporary. Once the shift ended and a new team started, Viktoria did not have anyone to advocate for her and experienced more mistreatment. She believed that she had been avoided by some of the midwives and did not receive the same level of attention as non-migrant women. Similarly to Anna's, Viktoria's limited knowledge of the language and the lack of financial resources that would allow her to earn, through private services, the position of “someone's patient”, hindered her ability to control social relationships with healthcare providers. Although both Viktoria and Anna assumed some form of control over the situation by making connection with Ukrainian healthcare personnel, it was temporary and relatively precarious.

### 4.3. “Just to be on the safe side ...” – engaging in transnational healthcare practices

The last strategy that women engaged in involved mobilizing their social resources and personal relationships with healthcare providers in Ukraine. Only one woman declared that she had travelled back to Ukraine for a prenatal consultation to a physician she had known from her previous pregnancy. Instead of travelling, it was far more common to get in touch online with healthcare professionals that the women had known back in Ukraine. The strategy involved sending them screening results and asking for a second opinion. The exact form of transnational healthcare practices depended on women's economic resources and social networks. Women who had accessed private services in Ukraine or who had previously made arrangement by informal payment with physicians were far more likely to have an established contact with Ukrainian care providers and contact them in case they had any doubts. Daria was a well settled permanent migrant who worked as a sales manager. She explained that prior to the war, despite having formal access, she had rarely relied on healthcare services in Poland. Instead, as she explained, she had had a well-established network of care providers in Ukraine that she knew and used to attend before moving to Poland. Thus, after migrating, she used healthcare services in Poland only in emergency and used private preventive care (such as regular gynaecological consultations) when visiting family and friends in Ukraine. The
situation changed with the outbreak of the war, as Daria found it too risky to travel back to Ukraine. However, she continued to occasionally rely on this well-established network of care providers in Ukraine for her maternity care by sending them test results or asking for their second opinion:

> "I have a gynaecologist in Ukraine and I just sent her [my maternity] screening results (...). And this is why I decided on Health Care [a large network of private health clinics in Poland that Daria had limited trust in], because I have always known I can have support from my own gynaecologist in Ukraine, the one I trust. (...) So I just asked and checked with her [the physician in Ukraine] whether their [physicians' in Poland] recommendations were right." (I23, arrived in Poland in 2014 with her partner)

Having backup in Ukraine provided Daria with a sense of security. As she explained, even in cases when she had limited trust in her Polish physician, she did not seek another opinion in Poland, but relied on her physicians in Ukraine.

Similarly to Daria, Viktoria, a circular migrant, had rarely relied on healthcare services in Poland prior to the outbreak of the war. However, unlike Daria, she had not had formal access to publicly-funded care in Poland. When necessary, she had used healthcare services in Ukraine, often in publicly-funded clinics where, as she admitted, she had occasionally made small informal payments to doctors in order to receive more attentive care. Unlike Daria's, Viktoria's social and financial capital did not enable her to have an established network of care providers in Ukraine that she could contact in case of any questions. After the outbreak of the war and when granted the temporary protection status, Viktoria mainly relied on publicly-funded maternity care in Poland. As described above, when she wanted a second opinion, Viktoria paid for one private consultation in a private clinic in Poland.

Irina, a businesswoman from Kiev who came to Poland by herself after the outbreak of the war and pregnant with her first baby, explained that, although she mostly relied on publicly-funded maternity care in Poland, she stayed in contact with her care provider in Ukraine. Irina experienced a sharp loss in her purchasing capabilities and possibilities of mobilizing social networks after fleeing to Poland. As she struggled to understand Polish and moved several times during her first months in Poland, Irina received fragmented care. She also had a limited understanding of how maternity services worked in Poland and craved a form of a relationship with a care provider she was used to having in Ukraine. To guide her through the system, Irina got in touch with an aid organization and relied on interpreting services provided by volunteers. However, the social relationships she developed with the volunteers did not allow her to establish social relationships with healthcare personnel. She found healthcare services in Poland confusing and impersonal. Thus, Irina occasionally sent her screening results to a physician she had known in Ukraine, asking for a second opinion. This provided Irina with a sense of security and continuity of care she lacked in Poland.
5. Discussion

This article contributes to the literature on pregnant migrant women’s access to healthcare, analysing what strategies Ukrainian women deployed in the Polish context in the face of specific challenges that pertain, on the one hand, to accessing healthcare as a migrant person or a refugee and, on the other, to accessing quality maternity care as a pregnant woman.

A significant portion of the literature in migration studies addressed the experiences of racialised migrant women (understood as women from countries in the Global South going through pregnancy in countries of the Global North), and highlighted the racialisation of maternity care politics both at the discursive level (Erel, 2018; Gedalof, 2007; Hiemstra, 2021; Luibh'eid, 2013) and as an underpinning logic to the barriers and exclusions encountered while accessing healthcare (Sahraoui, 2021). Review articles showed that migrant women might face formal barriers, lack information about the healthcare system as well as economic resources to access them, and experience culturally insensitive care (Higginbottom et al., 2019; Zhu, 2023). Others have advocated for culturally-competent and interdisciplinary maternity healthcare able to address pregnant migrant women's specific social position beyond their clinical needs (Fair et al., 2020). Public health and midwifery studies have further studied what types of barriers persist and how they function. Crowther and Lau (2019) highlighted for instance, drawing on a qualitative study of Polish migrants in Scotland, the importance of communication and the building of individualised relationships to go beyond the problematization of migrant groups and the homogenisation it engenders. In line with findings emerging across the field and drawing on a case-study conducted in Norway, Bains et al. (2021) thus highlighted the need for better information provision, more use of interpretation services, better intercultural training of healthcare personnel as well as the possibility of accessing psychological support (Bains et al., 2021). Overall, most studies tend to mobilise the category of migrant pregnant patients in order to identify specific challenges and ways to address them, without focusing the research on the differences among migrant women, even when these are acknowledged or mentioned. In contrast, this article sought primarily to understand how Ukrainian migrants and refugees deploy their healthcare strategies in the context of existing inequalities in Polish and Ukrainian healthcare systems as well as whether and to what extent migrants' financial, social and cultural resources can account for differentiated access to quality maternity care in spite of or while sharing a similar position as a Ukrainian woman in Poland. In this sense, this article fills in a gap of addressing migrants' healthcare strategies in the context of existing wider inequalities in accessing quality care in transnational contexts, particularly as regards the division into private and public care.

For this purpose, we also drew on specific findings from research into maternity
healthcare as experienced by non-migrants, observing certain similarities such as the
crucial role of building personal relationships with care providers through the use of
private services and out-of-pocket payments in accessing more attentive maternity
care in Poland and Ukraine (Stepurko et al., 2013; Węgrzynowska, 2021). By
exploring the experiences and practices of Ukrainian migrant women accessing
maternity care in Poland, our study showed those strategies were also important for
migrant women. While social connections, time spent in Poland and cultural capital
played an important role in building such relationships, it was mostly economic
resources (and the ability to pay for private care) that enabled Ukrainian migrant
women to build stable and effective personal relationships with care providers and
access better care.

In our study, permanent migrants who had resided in Poland before the outbreak of the war and had economic resources were the most effective at mitigating the shortcomings of the Polish healthcare system. By mobilizing their cultural (proficiency in Polish language, knowledge of the system), economic (going private) and social (migrant and nonmigrant networks) resources, those women were able, more effectively than others, to secure attentive care for themselves. They were generally more focused on the quality of care, finding healthcare providers they could trust and building relationships with them compared to circular and wartime migrants. Similarly to some of the more privileged migrants who arrived in Poland after the outbreak of the war, they also continued to rely to some degree on healthcare services in Ukraine and the providers with whom they had established relationships.

In contrast, circular migrants rarely had the resources to protect themselves from
the shortcoming of Polish healthcare services. The newly granted formal access to
healthcare and social services in Poland provided them with a certain level of
agency, as they no longer depended entirely on their trips to Ukraine for healthcare.
However, because of the risks associated with travelling back to Ukraine, many of
them lost the possibility to use the Ukrainian healthcare services. Unlike the most
privileged migrants, circular migrants rarely had the social networks and economic
resources to contact physicians online in Ukraine or build relationships with
healthcare personnel in Poland. Therefore, they mostly relied on publicly-funded
care in Poland and were primarily focused on timely access rather than the quality or
trustful relationships with their care providers.

As regards migrants who arrived in Poland after the outbreak of the full-scale war,
their lack of social networks and loss of economic capabilities was particularly
severe due to the suddenness of their migration and, frequently, a chaotic migration
trajectory. They had little time to compensate for that loss, e.g., by learning Polish or
finding a job. Some women, who managed to establish relationships with Ukrainian
or Polish families and aid organizations, could partially compensate for the loss of
social and economic resources and be more successful in accessing quality care.
However, it required a certain level of knowledge, confidence and access to social
networks to find information about aid organizations or to make contact with people
in Poland who offered support. It commonly happened that one person a woman knew referred her to another person who could offer help. Moreover, women's experiences showed that these relationships were often insufficient to allow

successful and lasting relationships with healthcare providers and continuous access to better care. The benefits drawn from such connections were uncertain and precarious. While some women built longlasting relationships with Polish or Ukrainian volunteers that helped them to access quality care, others received support that was temporary and contingent. This illustrates the precarious nature of rapidly built post-migration social relations. It is only when articulated with knowledge as to how healthcare services worked and, most importantly, with the availability of economic resources, that such relations provided a stable access to quality maternity care.

## 6. Strengths and limitations

We acknowledge some limitations to these results as Ukrainian women in Poland constitute a heterogeneous group with various migration trajectories, plans and resources. While we aimed to show certain trends and social profiles of Ukrainian migrant women and went beyond a narrow focus on post-war migrants, we certainly did not exhaust all the diversity. For example, we did not account for Ukrainian women from the Roma community who arrived in Poland after the outbreak of the war. We also did not account for women living in longterm organised housing facilities such as refugee centres or shelters. Those two groups constitute a particularly vulnerable population that require further research.

## 7. Conclusions

The outbreak of the full-scale war in Ukraine forced Ukrainian migrant women to adapt to a different reality and develop a new set of strategies of access to ensure individual and family wellbeing. We were able to show how inequalities in access to quality maternity care took shape through Ukrainian migrants' healthcare practices and the determining role of economic resources in particular.

While the question of multiple barriers faced by migrants' in accessing healthcare and the risk of substandard experiences within healthcare services has been largely documented (for a review article see Nowak et al., 2022; for a collection of case-studies, see Sahraoui, 2020), our research demonstrates the necessity to critically examine and unpack the 'migrant' category in that it foregrounds how Ukrainian pregnant women in Poland have different experiences of perinatal and maternity care according to their levels of economic capital and its articulation with existing and newly established social networks. In this way, the findings of this article
contribute to the wider discussion on migrants' healthcare practices by highlighting the importance of looking at those practices in the context of larger inequalities in the host and home societies. It shows that the crucial role of building personal relationships with care providers (typically by mobilizing economic capital and accessing private care services) in ensuring more attentive maternity care in Poland and Ukraine is also valid for migrants and, as in the case of non-migrant populations, available only to better-off women.

Thus, it is not only the process of migration that impacts migrants’ healthcare strategies, but also the inequalities embedded in the “local” healthcare services, that shape the strategies of non-migrant populations, and which play a crucial role in determining migrants’ practices as well.

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