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Structural barriers to prenatal care for migrant women at the United States–Mexico border: a qualitative study

Original publication here: https://doi.org/10.1016/j.puhe.2025.105986

Dec 2025

K.M. Gonzalez, W.R. Matias, A.M. Mohareb, D. Sridhar

Abstract

Objectives

Recent United States (US) immigration policies have left thousands of asylum seekers stranded in Mexican border cities with limited access to healthcare. Pregnant women are particularly vulnerable, often facing substantial barriers to receiving adequate prenatal care (PNC). This study aimed to describe the state of PNC delivery at the US–Mexico border through the challenges, experiences, and perspectives of healthcare workers (HCWs).

Study design

Qualitative study.

Methods

Semi-structured interviews were conducted with 10 HCWs (6 nurses and 4 physicians) who volunteered at non-governmental organization (NGO)-operated clinics in Matamoros and Reynosa between 2019 and 2023. Interviews were conducted in June–July 2023 and analyzed using thematic analysis.

Results

Three inductive themes emerged: (1) structural violence; (2) resource limitations; and (3) care fragmentation. Participants reported that PNC frequently fell below international standards. Continuity of care was disrupted by patient transience, limited infrastructure, and reliance on short-term staffing. Additional barriers included shortages of specialized providers, fragmented medical records, institutional racism, and the impacts of cartel-related violence.

Conclusions

This study underscores the structural and systemic barriers shaping maternal healthcare delivery in humanitarian border settings. Improving care for pregnant migrants will require comprehensive policy reform, strategic resource allocation, and rights-based, cross-border approaches. Future research should engage migrant communities and local providers to develop responsive models that bridge the gap between inclusive policy and frontline care.

1. Introduction

Migration from Central America and Mexico has sharply increased in recent years, driven by poverty, violence, and exacerbated by climate change, COVID-19, and economic disruptions.¹ Recent United States (US) policy shifts have fundamentally reshaped the asylum process, creating significant barriers for migrants.²

The Migrant Protection Protocols (MPP) of 2019—also known as the “Remain in Mexico” policy—required asylum seekers to return to Mexico while awaiting their US immigration proceedings.³ Title 42, enacted in March 2020 under the Public Health Service Act of 1944, authorized the US government to expel asylum seekers under the pretext of COVID-19 prevention.⁴^,⁵ Together, these policies restricted border access and left nearly 20,000 asylum seekers stranded in dangerous Mexican border cities.⁶ Although both policies have since been rescinded, public health experts widely condemned them for lacking scientific justification and creating lasting barriers to healthcare, shelter, and other essential services.⁶^,⁷

Pregnant women are especially vulnerable, often lacking adequate prenatal care (PNC), clean water, sanitation, safe shelter, and proper nutrition.⁸ They face heightened risks of violence, including documented cases of miscarriages, kidnappings, rape, and abuse following expulsion.⁹ Timely PNC—the healthcare women receive during pregnancy—is essential for optimizing maternal and neonatal health.¹⁰ Newborns born to mothers without PNC are three times more likely to have low birth weight and five times more likely to die.¹¹ This study defines ‘adequate’ PNC based on the World Health Organization’s 2016 antenatal care (ANC) model, which recommends at least eight provider encounters during pregnancy.¹²

Although reports highlight the challenges faced by pregnant women,⁹^,¹³^,¹⁴ peer-reviewed literature on PNC delivery at the US–Mexico border remains scarce. This study aims to address this gap by describing the state of PNC delivery through the challenges, experiences, and perspectives of healthcare workers (HCWs) amidst the prevailing political climate.

2. Methods

2.1. Study design

We used a qualitative study design, employing semi-structured interviews to explore HCWs’ perspectives on PNC delivery and the factors influencing its provision. We adopted an interpretive standpoint, viewing reality as subjective and ever-changing, emphasizing that multiple perspectives can coexist and influence understanding.¹⁵ This approach guided our recruitment strategy. We focused on HCWs rather than patients to gain broader insight into potential systemic barriers and avoid ethical challenges associated with interviewing migrants. Reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines,¹⁶ with a completed checklist provided in the Supplementary data.

2.2. Sampling and participant recruitment

We employed maximum variation sampling, a purposive sampling strategy aimed at capturing diverse perspectives and experiences.¹⁷ Participants were recruited from Global Response Medicine (GRM), an international humanitarian non-governmental organization (NGO) that provided free clinical and specialty care to asylum seekers at the US–Mexico border from 2019 to 2023 through clinics in Matamoros and Reynosa.¹⁸

GRM operates on a volunteer-based system. Eligible participants were HCWs—including physicians, nurse practitioners, midwives, and nurses—who had provided PNC at GRM’s Matamoros or Reynosa clinics at least once and consented to participate. No further exclusion criteria were specified. We leveraged our professional contacts within GRM and Massachusetts General Hospital (MGH), a partner hospital. HCWs were recruited through direct email invitations facilitated by these contacts, as well as snowball sampling¹⁷ from initial respondents.

We sampled ten participants with relevant experience to ensure high-quality data.¹⁹ No invited participants declined or dropped out.

2.3. Data collection

We developed a semi-structured interview guide (see Supplementary data) informed by investigator experiences at the border, guidelines for semi-structured interviews,²⁰ and a review of existing literature.²¹ The guide was pilot tested through internal review by the research team²¹ and field-tested with two potential participants.²⁰

Between June and July 2023, we conducted interviews with eligible participants after confirming consent. Interviews were conducted by KMG, a Master of Public Health candidate trained in qualitative methods, under the supervision of experienced qualitative researchers. Participants were informed of the interviewer’s background in global health. An optional informational call was offered to discuss study objectives, address questions, and schedule a suitable interview time.

To protect confidentiality, names were not recorded, identifying data were removed during transcription, and identity codes were applied to all transcripts. To maintain privacy, all interviews were conducted remotely via Microsoft Teams, without observers present, at times selected by participants. At the start of each interview, participants were informed of the voluntary nature of their involvement. Participant characteristics (e.g., role, organization, and experience providing care to pregnant patients) were then collected verbally and documented in field notes.

All interviews were conducted in English and lasted 22–59 min, with a mean duration of 43 min. They were audio-recorded and transcribed verbatim. We reached data saturation when no new themes emerged.²² No repeat interviews were conducted, and transcripts were not returned to participants for review.

2.4. Data analysis

We employed a thematic approach to analyze the data, aiming to reveal patterns and themes within the dataset.²³ This approach was chosen for its foundational status in qualitative research and its ability to uncover unforeseen insights, particularly given the limited peer-reviewed literature on this topic. An inductive approach allowed themes to emerge directly from the dataset.²³ We adopted Braun and Clarke’s 6-phase process for thematic analysis.²⁴

KMG performed primary coding with regular input and oversight from DS. We read through the transcripts for familiarization and performed line-by-line coding on the first three transcripts to develop initial codes. These codes were iteratively organized into a detailed coding tree, which grouped related codes into categories and subsequently overarching themes. Themes were cross-referenced with coded extracts from all transcripts.²⁵ During the writing of the results, we refined the codes by comparing evolving interpretations against the raw data to ensure accurate representation, as per Charmaz’s constant comparative approach.²⁶ This method also guided probing in later interviews.

We used NVivo 14 for data management and analysis,²⁷ and Miro to visualize thematic relationships.²⁸ No formal participant checking was conducted.

2.5. Reflexivity

To enhance rigor, we adopted reflexivity practices.²⁹ We maintained a detailed journal documenting methodological decisions, potential biases, and interpretations of the data. Given participants’ awareness of our border experience, we presented ourselves as informed but intentionally neutral to encourage fuller responses.³⁰ We also employed reflexivity to account for prior professional relationships with several participants, recognizing that existing familiarity could influence the data collection process. We actively reflected on our positionality as US- and UK-based public health researchers with previous experience in humanitarian contexts.

3. Results

Participant characteristics are summarized in Table 1. We recruited 10 HCWs, including 6 nurses and 4 physicians. Nine had provided direct PNC at GRM’s Matamoros or Reynosa clinics. Although P2 did not provide direct care, their insights into border-based service delivery were included following transcript review. Findings are organized through three overarching themes: (1) structural violence; (2) resource limitations; and (3) care fragmentation. Additional participant quotes are provided in the Supplementary data.

3.1. Theme 1: Structural violence

Structural violence refers to social systems—such as legal, political, and economic structures—that systematically disadvantage certain groups and restrict access to basic rights and resources.³¹

3.1.1. Denial of care

Participants described how migrants were frequently turned away from hospitals without evaluation, received incomplete diagnostics, or were denied ambulance transport and admission. Routine PNC through state systems were often inaccessible due to financial barriers, and even those who delivered in hospitals were discharged quickly without postpartum care.

“Some people just flat out get turned away. Or there were situations where we would send someone to the hospital … and they didn’t even do the workup … At the public hospital, my understanding is [that] care should be free, but a lot of times you have to provide your own supplies and purchase [your own] medicines. – P1

3.1.2. Discrimination and language barriers in healthcare access

Language barriers and racial discrimination, particularly against Haitian migrants, were cited as major obstacles within Mexican healthcare institutions.

“The Haitian population [is] really discriminated against and not provided care [for]. [Hospitals are] just churning Haitians away or [providing] basic care and then turning them away. – P7

3.1.3. Cartel violence and safety concerns

Fear of cartel violence deterred migrants from accessing local services. Participants noted that unsafe conditions—such as pregnant women being unable to walk unattended—compromised their sense of safety, which may adversely affect maternal health.

“I learned about the drug cartels there … They’re patrolling the streets and it’s hard to know who is who. So, for a pregnant woman to walk the streets unattended, [it] can be dangerous.” – P4

3.1.4. Overburdened public health system

Participants emphasized that the Mexican public health system was already under strain and faced additional pressure in responding to the needs of the migrant population.

“They’re already taking care of very destitute groups of Mexicans [and] are also expected to handle this new influx of migrants.” – P6

3.2. Theme 2: Resource limitations

Resource limitations refer to constraints in space, staffing, or supplies that compromise the consistent delivery of quality healthcare.³²

3.2.1. Shortage of specialized providers

Participants noted a significant lack of specialists, particularly obstetricians and gynecologists. Most providers were generalists, and many participants reported working beyond their usual scope of practice, gaining experience through their clinic work at the border.

“This is not my area of expertise at all … I don’t have the kind of comprehensive knowledge of what to expect at a particular stage of pregnancy or what normal [is]. What [is] abnormal? That was all learned throughout my time in the clinics.” – P6

3.2.2. Limited medical supplies and diagnostic equipment

All participants described limitations in available supplies and diagnostic equipment. While basic labs and limited ultrasounds were accessible, budgetary constraints and reliance on external referrals restricted comprehensive screening for infections, congenital anomalies, and fetal growth.

“So that a pregnant woman was getting regular exams, ultrasounds, lab[s] … That kind of care is just not possible to maintain.” – P6

3.2.3. Lack of privacy in makeshift clinics

Participants noted that GRM clinics operated in makeshift spaces—such as courtyards, dining halls, or porches—where limited privacy impeded the ability to address sensitive issues like gender-based violence (GBV) or perform sexually transmitted disease (STD) screenings.

“We weren’t screening for STDs. No, because that means undressing them … There’s really no privacy in those clinics.” – P7

3.3. Theme 3: Care fragmentation

Care fragmentation is characterized by the distribution of care across multiple providers without consistent oversight, leading to disruptions in continuity and coordination.³³

3.3.1. Patient mobility disrupts follow-up care

Participants identified the mobile nature of the migrant population as a major barrier to continuity of care. Migrants frequently moved between cities while awaiting asylum or seeking safety or resources, sometimes traveling over 50 miles to access services.

“That person either crosses over or something happens to them, they disappear. You don’t know what happens to them … That’s not an element [that] can be accomplished there.” – P5

3.3.2. Short-term staffing reduces provider continuity

The use of short-term, rotating volunteers made it difficult for patients to see the same provider across visits. Participants noted that this disrupted continuity of care and hindered relationship-building and consistent follow-up.

“If we wanted to see [a patient] the following week, chances are they were going to see a different [provider] … You’re writing notes in their little prenatal book, hoping that the next person can pick up where you left off.” – P4

3.3.3. Fragmented medical records hinder clinical decision-making

Participants explained that inconsistent medical records hindered effective follow-up and care planning. Key clinical data—such as pregnancy history, group B streptococcus (GBS) status, and prior complications—were often unavailable. Several participants expressed concern about tracking preeclampsia, which they noted was particularly common among Haitians, who comprised the majority of GRM’s patients.

“Part of prenatal care is pregnancy history. If someone has a history of pregnancy loss, that’s a very important indicator for the current pregnancy.” – P5

Although not described as a standalone barrier, participants reflected on the emotional and ethical toll of delivering care in this context. Communication challenges—particularly the absence of trained interpreters—limited their ability to assess patients and discuss sensitive topics. Several described feelings of helplessness when unable to meet patients’ needs or provide the level of care they believed was ethically appropriate.

4. Discussion

This qualitative study explored PNC delivery along the US–Mexico border from the perspective of HCWs. Three interrelated themes emerged as critical to understanding the barriers to care: structural violence, resource limitations, and care fragmentation. Despite dedicated efforts of organizations such as GRM, the quality and accessibility of PNC for migrants often fall below international standards.

Findings align with prior research documenting systemic barriers to healthcare access for migrant populations at the US–Mexico border, including care denial, discrimination, and institutional neglect.⁶^,³⁴ Although Mexico’s revised General Health Law guarantees universal access to public health services,³⁵ implementation remains inconsistent, and migrants continue to face substantial access barriers.³⁶ Pregnant women are especially vulnerable to neglect and abuse.⁶^,⁹^,³⁴ Asylum seekers more broadly are perceived as overburdening Mexico’s strained public health system, leading to discrimination from both healthcare providers and the public.³⁴^,³⁷ Participants further emphasized that pervasive cartel violence—particularly in border cities—deters migrants, especially pregnant women, from seeking necessary care, increasing stress and the risk of adverse pregnancy outcomes.⁶^,⁹^,³⁴^,³⁸^,³⁹

Our findings also underscore structural challenges in humanitarian health delivery. Participants described shortages of specialized staff, diagnostic equipment, and medications—findings that echo prior research on NGOs at the border, including GRM and Médecins Sans Frontières (MSF), which operate under critical resource constraints.³⁴ GRM’s clinics in Reynosa were mobile, and while mobile clinics have expanded PNC access in other low-resource settings,⁴⁰ their effectiveness depends on sustained staffing, infrastructure, and service scope.⁴¹

With these settings, privacy-related limitations—particularly in makeshift clinical spaces—emerged as barriers to addressing sensitive issues such as GBV and conducting essential screenings. Similar concerns have been documented in mobile clinics in the US,⁴² South Africa,⁴³ and Brazil.⁴⁴ Participants also noted that fragmented or incomplete medical records hindered clinical history tracking and risk assessment, echoing broader systemic challenges in humanitarian contexts where inter-organizational data sharing remains limited.⁴⁵ Comprehensive medical, social, and reproductive histories are critical for early detection and management of high-risk pregnancies, including hypertensive disorders such as preeclampsia,⁴⁶ which participants noted were especially prevalent among Haitian populations—who accounted for the majority of GRM’s patient population.⁴⁷

While our findings affirm existing literature, they also provide novel insight into the delivery of PNC in border humanitarian contexts. For example, participants emphasized how rotating staff and the transient nature of patients compromised relationship-building and the ability to provide consistent longitudinal care throughout the prenatal period. These disruptions extend beyond general access barriers and point to gaps in long-term care.

This study has several limitations. Its small sample size and recruitment from a single NGO may limit generalizability. Intermittent, rather than continuous, volunteer participation may not fully reflect the experiences of full-time frontline clinicians. The focus on US-based HCWs excluded valuable perspectives from local Mexican providers and migrants, which future studies should prioritize. Additionally, the rapidly evolving policy landscape and fluctuating border conditions may affect the long-term relevance of our findings.

4.1. Conclusion

This study reveals an escalating humanitarian crisis at the US–Mexico border, where basic PNC remains out of reach for pregnant migrants. Structural violence, resource limitations, and care fragmentation undermine the quality and accessibility of maternal healthcare. Despite the efforts of humanitarian organizations, entrenched systemic barriers persist. Addressing these challenges will require comprehensive policy reform, strategic resource allocation, and coordinated binational action grounded in human rights. Strengthening integration between NGOs and formal healthcare systems could enhance service coordination, equity, and outcomes for underserved border communities.⁴⁸ Future research should incorporate the perspectives of Mexican healthcare providers and migrant communities, using community-based participatory approaches to develop rights-based, responsive models of care that bridge the gap between inclusive policy frameworks and on-the-ground healthcare delivery.³⁶

Author statements

Ethical approval

This study was approved by the Usher Masters Research Ethics Group (reference no. UM23247), Usher Institute, University of Edinburgh. Written informed consent was obtained from all participants.

Data availability

The data that has been used is confidential.

Author contributions

KMG contributed to conceptualization, methodology, project administration, investigation, formal analysis, data curation, and writing the original article. WRM contributed to reviewing and editing the article. AMM contributed to methodology, reviewing, and editing the article. DS contributed to reviewing and editing the article, validation, and supervision.

Funding

This work was supported by the US National Institute of Allergy and Infectious Diseases (grant number T32 AI007433, awarded to WRM) and the Harvard University Center for AIDS Research (CFAR), an NIH-funded program (grant number P30 AI060354, awarded to WRM). The funders had no role in study design, data collection and analysis, preparation of the manuscript, or decision to publish.

Competing interests

DS is a member of the editorial board for Public Health. The other authors declare no competing interests.

Acknowledgements

We are grateful to the participants who took part in this study. We acknowledge the collaboration of the GRM team, particularly Brendon Tucker and Clara Lee Arnold. Our appreciation extends to the MGH Center for Global Health, especially Dr. Lindsey Martin and Kristen Giambusso, for their valuable support during the planning stages of this research.

References: References Public Health Vol. 249

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Psychological Sequelae of Drone Attacks

November 6, 2025

Published on Psychiatrist.com – Primary Care Companion for CNS Disorders, Prim Care Companion CNS Disord 2025;27(6):25f04056

Joseph L. Bonvie, PsyD; Sofia E. Matta, MD; Serhii Andriichenko, MD; Ihov Slobodian, MD; Andrea Leiner, APRN; Yulia Brockdorf, RD; Theodore A. Stern, MD

Lessons Learned at the Interface of Medicine and Psychiatry

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss diagnosis and management of hospitalized patients with complex medical or surgical problems who also demonstrate psychiatric symptoms or conditions. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.

This article is the result of a collaboration between Ukrainian clinicians, both uniformed and civilian, and Home Base (a partnership between Massachusetts General Hospital and the Boston Red Sox committed to healing the invisible wounds of war).¹In March 2025, Global Response Medicine, an organization focused on delivering and managing humanitarian aid worldwide, facilitated a reciprocal partnership between Home Base and the Ukrainian Ministries of Interior and Health. This initiative was designed to share evidence-based practices and clinical innovations in support of Ukrainian military personnel and their families.

This article seeks to illuminate a newly emerging form of combat stress, one shaped by the relentless and psychologically corrosive nature of modern drone warfare. If you have ever wondered what it is like to live under the threat of a drone attack or thought about how drone attacks differ from those of artillery fire or ground assaults or been uncertain about how to treat someone who has developed combat drone-related posttraumatic stress and anxiety, then the following case vignette and discussion should prove useful.

CASE VIGNETTE

Mr A, a 28-year-old active-duty Ukrainian soldier, was returning to his post when the ground beneath his feet suddenly gave way. He had been unaware of the Russian-operated drone that had dropped munitions onto him. A second strike followed seconds later as he lay wounded, having lost all motor function in his legs.

Although his uninjured comrades applied tourniquets to his legs to control the bleeding, evacuation was impossible, as reconnaissance drones remained overhead searching for targets. Mr A was left isolated, immobile, and exposed, as his comrades sought cover.

When one drone continued to drop ordnance on him, another drone hovered nearby and recorded his distress (pain, fear, and helplessness) for propaganda purposes over social media. Mr A endured 5 more drone assaults before losing consciousness. Left for dead, the attacks paused, and Mr A’s comrades attempted to evacuate him. However, a reconnaissance drone detected their movement and dropped additional munitions and an incendiary device. Upon regaining consciousness, Mr A extinguished the flames on his body with his hands, after which chemical munitions were dropped by the drone rendering him unconscious once again.

Mr A was evacuated 14 hours later, under the cover of night. His injuries included bilateral lower-limb burn-blast injuries with severe tissue loss and infections that required several amputations; these were traumatic for him. During Mr A’s recovery and rehabilitation, he watched footage of his attack circulating on social media, re-exposing him in vivid detail to the event, and now accompanied by streams of “likes,” unsolicited opinions, and voyeuristic commentary from a distant, virtual audience.

DISCUSSION

Why Are Drones Increasingly Used in Military Conflicts?

For the purposes of this article, the term drone refers to an unmanned aerial vehicle or unmanned aircraft system that is either remotely piloted or utilizes software for autonomous flight. Modern drone performance varies based on propeller configuration, intended purpose, flight range, and payload capacity.

While the US military employed drones extensively during the wars in Iraq and Afghanistan, the commercialization of drone technology since the Global War on Terror (GWOT) has profoundly reshaped modern warfare on sea, air, and land. The proliferation of civilian drone platforms is fueled by their low cost, operational simplicity, and expendability, making them a potent force multiplier.²Rapid advancements in tactical technology since Russia’s full-scale invasion into Ukraine in 2022 has effectively made Ukraine a battlefield laboratory that has re-engineered the methods and means of conducting warfare and their associated human consequences.³

The most commonly used drones in Ukraine are civilian short-range first-person view (FPV) multirotor copters, modified for tactical purposes. Pilots control these FPVs using virtual reality headsets, providing them with gamified situational awareness of the battlefield. As drone operators gain experience, they advance to more complex aerial missions and platforms. FPV drones typically engage targets by dropping munitions, such as mortar shells and grenades, or by performing kamikaze-style attacks, detonating on impact. A single exploding FPV drone can cost between $200 and $500, a small fraction of the price of guided artillery shells that are 10–15 times more expensive.⁴In contrast, modern Russian battle tanks cost approximately $4 million each and can be effectively destroyed by a small number of these inexpensive drones. This stark cost disparity underscores a significant strategic shift in modern warfare, where affordable unmanned systems can deliver disproportionate battlefield effects.

Composed in large part of civilian volunteers—teachers, laborers, and students—who now constitute approximately 60%–75% of Ukraine’s current military force,⁵the Ukrainian defense has rapidly integrated drone technology into its defense strategy and become a contemporary example of asymmetric warfare. Russia, anticipating a swift and decisive victory, was initially unprepared for this unconventional resistance. However, Ukraine’s operational success compelled Russia to adapt quickly, accelerating its own investment in and deployment of drone capabilities, thereby initiating an arms race in unmanned systems that neither side had fully anticipated at the outset of the conflict.⁶Ukraine’s production target for 2025 is 4.5 million drones produced from Ukrainian factories alone, which is double their production from 2024, and slightly more production than what Russia is anticipated to produce by the end of 2025.⁷

How Much Warning Can a Person Receive Before a Drone’s Guns or Missiles Hit Their Target?

The distinct sound of an approaching drone (like the hum of swarming hornets) has become an ominous signal of imminent danger that those familiar with the trenches of Ukraine have likened to a “serious psychological attack.⁸” A volunteer group that builds FPV kamikaze drones (the “Wild Hornets” unit) for the Armed Forces of Ukraine reports that an FPV drone can travel in excess of 186 mph.⁹Even, smaller FPV drones typically travel at 37 mph, which means that people cannot outrun a pursuing FPV platform.¹⁰

Large government and military drones, typically weighing over 150 kg, often operate at extremely high altitudes, with some surveillance platforms flying between 22,000 and 50,000 feet. At these elevations, they are virtually undetectable from the ground, since sound dissipates long before it reaches the surface, and visual identification is nearly impossible without advanced tracking systems. In contrast, smaller drones, such as microdrones (under 250 g) or small unmanned aerial systems (250 g–25 kg), tend to fly much lower, typically between 500 and 650 feet.¹¹These low-flying platforms are nearly silent and invisible above noisy battlefields, making them highly effective for reconnaissance or surprise attacks. However, drones delivering small munitions face limitations at higher altitudes, where gravity and wind introduce drift and reduce precision. To strike accurately, drones must descend to within 10–30 yards of their target, at which point their sound and movement may be detectable, giving soldiers a fleeting chance to react or defend themselves. The main warning sign of approaching danger is a change in the drone’s sound. As its sound intensifies, the drone is initiating an attack.

How Do Drone Attacks Differ From Other Methods Used in War?

Table 1 compares the characteristics of drones (eg, which deliver rapid and highly precise and inexpensive attacks under the direction of an operator who may be miles away) with other attack modes used in war zones.

How Does the Threat of a Drone Attack Induce Psychological Distress and Interfere With Normal Functioning?

Mr A’s experience illustrates the unpredictable nature of drone attacks and the helplessness they can instill in soldiers. Without hearing or seeing the drone, Mr A sustained a catastrophic injury and was subjected to what can only be described as a remote-controlled execution, which was filmed, shared, and consumed on social media by a distant, opinionated audience. This convergence of battlefield lethality and digital dissemination represents a novel dimension of modern warfare, with unique implications for psychological trauma, moral injury, and clinical care that we have yet to fully understand.

Experiencing a drone attack is a distressing and unforgettable event. The sound of a drone can evoke significant anxiety, especially in places like Ukraine where trading the front lines for the home front does not stop drone attacks. Some Ukrainian clinicians have started referring to the drone attack–related clinical presentations they are seeing as “dronophobia” due to the unique hypervigilance behavior with corresponding hyperarousal and avoidance behaviors.⁸For those who operate drones or have become accustomed to enemy drone activity, their anxiety may diminish as the sounds become more familiar. However, for many citizen soldiers and battle-hardened service members, the ongoing threat of drone attacks contributes to persistent hypervigilance and hyperarousal. Although drones have become a defining feature of modern warfare, we still know little about their psychological impact. Much of what we now recognize as drone warfare has taken shape on the battlefields in Ukraine, where these systems have been used on an unprecedented scale since Russia’s full-scale invasion on February 22, 2022. Because the war in Ukraine is so recent, the long-term psychological sequelae, on both soldiers and civilians, are still unfolding. A Ukrainian psychiatrist forewarned that the United States’ benign use of drones for weddings and real estate could become deeply triggering in a postwar Ukraine. As with previous conflicts, such as those during the GWOT, the true human consequences often take years, sometimes decades, to fully emerge and be acknowledged. This case of Mr A offers a window into the psychological realities of a new kind of asymmetrical warfare.

Many Ukrainian service members report that being within 5–10 miles of the front, well within the active range of FPV drones, requires constant vigilance: listening for the distinct hum of approaching drones while continuously scanning the sky. To adapt to the ever-present threat of attack, soldiers seek cover; make short, abrupt movements when the sound of drones fade; scan for nearby cover; peek around corners before crossing open spaces; and look upward frequently. Their constant skyward scanning exposes added vulnerability to the dual threat of hidden ground mines. Many soldiers avoid wearing tactical headphones out of fear that they will not hear an approaching drone, and some refuse to ride in military vehicles, which were once considered safe but are now viewed as prime targets.

Relatives of soldiers who have experienced drone attacks often notice significant behavioral changes. Before drone anxiety took hold, soldiers on leave would brighten their homes by opening curtains. Now, hundreds of miles away from the front, they keep their windows covered and lights dimmed, with furniture pushed to the edges of rooms to allow for unobstructed movement. During air raid sirens, while families seek shelter, these soldiers scan the skies from windows. Even simple activities, like walking outdoors with their children, are accompanied by upward glances. These behaviors reflect a durable state of hypervigilance: survival instincts and habits deeply ingrained by frontline experience and reinforced by the country’s persistent threat of drone attacks. This constant, looming danger makes it difficult for such adaptations to fade, even in relative safety.

Where Can a Person Feel Safe From the Threat of Drone Attacks?

Based on our Ukrainian coauthors’ experience treating service members, a sense of safety comes from minimizing exposure to open and vulnerable spaces. Many soldiers and civilians avoid windows, which mirrors their frontline behavior. On the battlefield, the most dangerous location is a dugout without overhead cover; soldiers prefer trenches with roofs or some form of overhead protection.

When away from the front, soldiers often seek windowless rooms or shelter in basements (ie, spaces that provide a greater sense of security against drone threats). Similarly, civilians find refuge underground (eg, in parking garages, subway stations, or basements). During a visit by Home Base clinicians to Ukraine, a “two-wall” shelter-in-place guideline was recommended to maximize protection. Many Ukrainians relocated from heavily targeted urban centers to private country homes, seeking distance not only from drone attacks but also from the psychological strain of continuous urban bombardment.

Who Is Most Susceptible to the Psychological Sequelae of Recent or Imminent Drone Attacks?

While real-world training and tactical preparation enhance a soldier’s ability to respond to the threat of a drone attack, the current reality is this knowledge offers limited protection against the stealth and precision of modern drone warfare. The persistent presence of drones can generate chronic psychological stress, and many soldiers report heightened anxiety, even when no immediate threat is apparent. Civilian soldiers, which is what most of Ukraine’s soldiers are, who are predisposed to anxiety, phobias, and distrust or who lack effective coping mechanisms are being found to be particularly susceptible to severe psychological distress from the threat of drone strikes.

Individuals who have experienced a drone strike, particularly those injured by one, are at heightened risk for developing persistent psychological symptoms, a vulnerability intensified by the ongoing threat of repeated attacks. For affected Ukrainian soldiers, the high likelihood of returning to active duty further increases their exposure to combat stressors. Likewise, the scale of Russian drone strikes on Ukrainian cities and towns raises concern that the broader civilian population faces an elevated risk of drone-related psychological symptoms.¹²

What Types of Physical and Psychological Symptoms Can Arise in the Context of Drone Attacks?

Hospitalized military personnel often develop psychological symptoms of posttraumatic stress (eg, with intrusive symptoms, avoidance behavior, and psychophysiological arousal) and anxiety disorders (eg, panic attacks, phobic reactions) following drone strikes. Substance use (involving alcohol and other psychoactive substances) is frequent among those who have been exposed to a drone attack, particularly those on the front or returning to the front where a high probability of re-exposure exists. Sleep disturbances (especially insomnia and nightmares) are common, with those attacked during dusk or at nighttime reporting heightened distress. The impact of such trauma can be stubbornly durable, especially in a country with permeable front lines, significantly impacting mental health and overall well-being.¹³

What Happened to Mr A?

Mr A experienced intense combat-related stress resulting from repeated battlefield drone attacks. Following evacuation, he was treated across 6 different medical facilities and underwent multiple surgical interventions, including bilateral lower limb amputations. Due to his fragmented care, brief hospitalizations, and lack of coordinated psychological support, Mr A was unable to initiate a structured rehabilitation process. Consequently, symptoms of acute stress disorder progressed, and he met diagnostic criteria for posttraumatic stress disorder (PTSD).

His anxiety significantly interfered with daily functioning. Mr A mitigated perceived threats by moving his bed away from windows, keeping his curtains drawn, maintaining all personal electronic devices in a ready state, and keeping the lights dimmed. Exposure to drone-like auditory stimuli triggered intense fear, anxiety, and feelings of helplessness.

Five months after his drone attack, Mr A was admitted to a specialized psychiatric polytrauma center that provided a multidisciplinary, integrative treatment protocol. His psychopharmacologic regimen included duloxetine (initiated at 30 mg/day and titrated to 60 mg/day), pregabalin (600 mg/day, tapered to 150 mg/day), quetiapine (100 mg/day), and carbamazepine (200 mg/day). These medications were complemented by multimodal therapeutic interventions, including individual evidence-based therapy (cognitive-behavioral therapy and eye movement desensitization and reprocessing); virtual reality for pain relief; group therapy; active sports (such as swimming); art therapy; ecotherapy; yoga; and acupuncture.

By the time of his discharge, Mr A’s symptoms improved sufficiently, and he no longer met diagnostic criteria for PTSD. Nonetheless, he continued to experience subthreshold generalized anxiety and a marked fear of drones, particularly during early morning hours.

CONCLUSION

The widespread use of drone platforms is largely attributable to their low operational cost, ease of use, and high mobility. These characteristics render drones particularly effective for high-risk military applications that mitigate operator exposure to danger while maximizing lethality against adversaries.

With the increasing prevalence of drone attacks, the distinct hum of an approaching drone, often likened to the swarming of hornets, has itself become a psychological weapon. The escalating pitch signals an imminent threat, which elicits fear and helplessness even before an attack. Whether directly experienced or witnessed in the aftermath, the auditory stimulus leaves a durable psychological imprint, with effects that may extend across generations, especially in conflict zones like Ukraine, where civilians endure repeated strikes that blur the boundaries between the front lines and the home front.

Addressing the psychological and societal consequences of drone warfare necessitates a comprehensive, integrated, multidisciplinary strategy.

As lessons from the GWOT have shown, this approach should integrate immediate medical care, ongoing mental health support that incorporates family, sustained surveillance, and community-based programs to mitigate the lasting impact of conflict, which is essential to address the consequences of war and the prolonged psychological and societal sequelae of drone attacks.^{14–16

Published Online: November 6, 2025. https://doi.org/10.4088/PCC.25f04056

© 2025 Physicians Postgraduate Press, Inc.

Submitted: August 12, 2025; accepted September 25, 2025.

To Cite: Bonvie JL, Matta SE, Andriichenko S, et al. Psychological sequelae of drone attacks. Prim Care Companion CNS Disord 2025;27(6):25f04056.

Author Affiliations: Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts (Bonvie, Matta, Stern); Harvard Medical School, Boston, Massachusetts (Bonvie, Matta, Stern); Center for Psychiatric Care and Professional Psychophysiological Selection of the State Institution, Kyiv, Ukraine (Andriichenko); Medical and Psychological Rehabilitation of the Medical Center, Novi Sanzhary, Ukraine (Slobodian); Global Response Medicine, Marco Island, Florida (Leiner); Defend, Aid, Widen, Future (DAWN), Hillsboro, Oregon (Brockdorf).

Bonvie, Matta, Andriichenko, Slobodian, Leiner, and Brockdorf are co-first authors; Stern is the senior author.

Corresponding Author: Joseph L. Bonvie, PsyD, One Constitution Road, Suite 140, Charlestown, MA 02129 ([email protected]).

Relevant Financial Relationships: None.

Funding/Support: None.

Acknowledgements: The authors would like to extend their sincere thanks to the Ukrainian Ministry of Interior and the dedicated clinicians who made this case vignette possible. As drone warfare continues to reshape the landscape of modern conflict, the mental and physical toll it exacts remains underexplored in the literature. This case offers a timely and important contribution to that emerging conversation.

Disclaimer: The views expressed in this material are those of the authors and do not reflect the official policy or position of the U.S. Government, the Department of Defense or the Department of Veterans Affairs. The case vignette is based on the experience of a real soldier who was treated at the Department of Psychosomatic Pathology, Territorial Medical Association, Ministry of Internal Affairs of Ukraine, in Kyiv. Due to ongoing hostilities in Ukraine, certain details have been altered to protect his identity and his unit.}

Clinical Points

First-person view drones provide a cost-effective means of delivering targeted strikes, with user-friendly controls that allow operators of varying skill levels to rapidly acquire piloting proficiency and conduct missions from a wide range of distances.
The sound of a drone often triggers intense anxiety, even when military personnel and civilians are far from the front lines.
The ever-present specter of drone attacks in war-torn nations forces soldiers and civilians to become hypervigilant.
Those who have experienced a drone strike, especially those who have been injured, are especially vulnerable to developing intense short-term and long-term psychological sequelae that are compounded by the ongoing threat of repeated attacks.
Optimal management of the sequelae of drone attacks involves a comprehensive, integrated approach to address immediate and long-term physical and psychological sequelae.

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