Your baby is so happy, active, uncooperative: How prenatal care providers contribute to parents’ mental representations of the baby

Midwifery 83 (2020) 102630

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Your baby is so happy, active, uncooperative: How prenatal care providers contribute to parents’ mental representations of the baby Tova B. Walsh University of Wisconsin-Madison School of Social Work, 1350 University Avenue, Madison, WI 53706, United States

a r t i c l e

i n f o

Article history: Received 2 August 2019 Revised 29 November 2019 Accepted 13 January 2020

Keywords: Attachment Bonding Mental representations Prenatal ultrasound

a b s t r a c t Background: Parents’ prenatal mental representations (i.e., thoughts and expectations) of their future child and relationship to that child have been associated with parenting and parent-child relationships after birth. Objective: To explore how prenatal care providers contribute to parents’ mental representations of the baby they are expecting. Methods: Routine prenatal ultrasounds of 22 pregnant women recruited through prenatal care were observed. Detailed notes were taken using an adaptation of the “Observation of Routine Screen Form” (Boukydis, 2006). Data collection included interaction among parents and providers relevant to the relational, rather than medical, aspect of the exam (e.g., comments on the “personality” of the fetus, speculation about how the future baby will be like and unlike parents). Principles of grounded theory informed thematic analysis of the data. Findings: Providers varied widely in their recognition of the relational aspect of prenatal ultrasound and their interactive style. Through informal interactions during ultrasounds, providers alternately inhibited, amplified, and shaped parents’ mental representations of their baby. Key conclusions and implications for practice: The manner in which providers narrate and interpret images has implications for parents’ prenatal mental representations of the baby. Given the importance of prenatal representations for future parenting and parent-child relationships, providers should attend to and facilitate parents’ efforts to develop their own mental representations and establish feelings of connection to the baby. © 2020 Elsevier Ltd. All rights reserved.

Introduction A routine prenatal ultrasound at approximately 20 weeks’ gestation is an integral component of prenatal care in most institutions (Breathnach et al., 2007), and it is becoming normative for expectant fathers to accompany expectant mothers to these appointments (Walsh et al., 2017). Conducted for medical diagnostic reasons, ultrasound examinations can also serve to enhance maternal-fetal and paternal-fetal attachment (Alhusen, 2008; Condon et al., 2013; Pretorius et al., 2006). Visualization of the fetus can make the pregnancy feel more real and reassure parents of fetal wellbeing, leading parents to deepen their imagining of the baby who will join their family (Ekelin et al., 2004; Sandelowski, 1993; Sjögren et al., 2004; Walsh et al., 2014).

E-mail address: [email protected] Social media: https://doi.org/10.1016/j.midw.2020.102630 0266-6138/© 2020 Elsevier Ltd. All rights reserved.

The development of mental representations of the baby and feelings of attachment are among the essential tasks that mothers and fathers undertake during the period of psychological reorganization that accompanies entry to parenthood (Slade et al., 2009). Prenatal representations are an active mental construction, specifically associated with imagining a future child and future relationship to that child, and informed by experiences in and perceptions of other important relationships, including particularly attachment experiences with one’s own parents (Bowlby, 1980; Larney et al., 1997; Zeanah and Barton, 1989). Over time, prenatal representations based on the imagined baby and one’s own early experiences shift to reflect observations and experiences of the actual baby (Ammaniti et al., 2013; Stern, 1995). Prenatal representations and feelings of connection to the fetus have been found to be associated with postnatal representations, pre- and postbirth parental behavior, parent-child relationships, and infant security (Benoit et al., 1997; Condon and Corkindale, 1997; HuthBocks et al., 2004; Siddiqui and Hägglöf, 2000).

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The developmental consequences of prenatal representations and parental- fetal attachment underscore the importance of better understanding how representations develop during pregnancy, and the sources of influence on those representations. The contribution of ultrasounds to prenatal representations and parental-fetal attachment is increasingly well established in the literature, with studies documenting the effects of visualizing the unborn baby via ultrasound on expectant parents’ perceptions of their baby as having intentions and feelings (Ammaniti and Gallese, 2014) and the influence of information imparted at ultrasound (e.g., detection of a “soft marker” that suggests heightened risk of a chromosomal abnormality) on maternal representations (Viaux-Savelon et al., 2012). This has led to the development of interventions for women at risk of experiencing pre-term birth (Pulliainen et al., 2019) and for substance-abusing pregnant women aimed at enhancing engagement in the ultrasound examination and thereby increasing feelings of connection to the fetus and investment in a healthy pregnancy (Boukydis, 2006; Boukydis and Stockman, 2012; Boukydis et al., 2006; Gibbons et al., 2010; Pajulo et al., 2016). These interventions rely upon specially trained sonographers or obstetricians to conduct the ultrasound examination, often in collaboration with a counselor or infant mental health professional. However, there is a paucity of knowledge about how healthcare providers who conduct standard ultrasound examinations in the context of low-risk pregnancies may contribute to parents’ mental representations of their baby. The purpose of this study was to explore how providers conducting routine prenatal ultrasounds for low-risk patients may contribute to parents’ mental representations of the baby. Methods Participants Twenty-two women pregnant with their first child and male partners of twenty of the women participated in the study. All were approximately midway through pregnancy at the time of data collection. Eligibility criteria included (1) pregnant woman experiencing a low-risk pregnancy and planning to complete a routine ultrasound examination at approximately 20 weeks’ gestation or partner planning to accompany mother for the ultrasound, (2) expecting first child, (3) over eighteen years of age, and (4) Englishspeaking. Mothers were predominantly in their 20s (67%), white (67%), married (61%) or cohabitating (30%), and employed full time (82%), and father demographics were similar. While two mothers and two fathers acknowledged initial ambivalence about the pregnancy, all participants intended to continue the pregnancy. It is important to note that this study speaks only to the experiences of pregnant women and their partners who had chosen to continue a pregnancy and anticipated becoming parents. Further details of sample characteristics are reported in Table 1. Procedures The current study is embedded in a larger mixed-methods study to examine expectant parents’ prenatal expectations for their future child and parent-child relationship, explore how ultrasound attendance engages and motivates expectant parents, and investigate expectant parents’ perceived needs for education and support during pregnancy (REMOVED FOR BLINDING). The goal of the overarching study is to inform and enhance services to foster positive transitions to parenthood. Pregnant women were recruited from four obstetrics and gynecology clinics associated with a large health system. The health system provides comprehensive pregnancy care, including a routine prenatal ultrasound with a registered diagnostic medical sonographer at approximately 20 weeks’

gestation. Flyers about the study included the information that the study was open to both pregnant women and their partners if they had a partner who would accompany them to the 20-week ultrasound examination. The researcher asked each prospective participant if she was currently partnered, if she expected her partner to attend the 20-week ultrasound examination, and if she would be comfortable participating in the study together with her partner. If all responses were affirmative, the researcher asked the patient for contact information to contact her partner regarding the study. (Note: all of the partnered women in this sample had male partners.) The researcher met participants at the clinic prior to the ultrasound appointment, provided study information in writing and gathered written consent, and participants completed a brief demographic questionnaire. The researcher accompanied participants to the typically hour-long appointment, quietly observed and recorded information following the protocol described below. Detailed notes were taken, including some verbatim quotes. Across 22 observations, seven sonographers conducted the ultrasounds. All sonographers were white women. Following the ultrasound, mothers, and fathers when present, were interviewed individually. Each participant was compensated $50. Data were collected between November 2015-August 2016. The study was approved by the (REMOVED FOR BLINDING) Institutional Review Board. Measures Demographic questionnaire Items assessed participant age, education level, employment status, annual household income, relationship status, and pregnancy intendedness. Observation protocol The researcher took notes using an adaptation of the “Observation of Routine Screen Form” (Boukydis et al., 2006). The form was modified for the current study to record the engagement of fathers in addition to mothers, and the nature as well as number of questions and comments during the exam. Data collection included the number and nature of questions asked and comments made by each parent and by the provider relevant to the relational aspect of the exam (e.g., perceptions of the fetus, speculation about what the baby will be like and what parenting the baby will be like), and the degree and quality of interaction during the exam. Data analysis Principles of grounded theory (Corbin and Strauss, 2008) informed a thematic analysis of the data. This methodological approach facilitates the development of deeper theoretical understandings of important psychological phenomena in specific contexts and with specific populations (Elliott et al., 1999). The goal of the current study was to explore how providers contribute to parents’ prenatal mental representations of the baby, and thematic analysis focused specifically on themes related to the interaction between parents and sonographers as it relates to the social and relational aspects of ultrasound (and not the medical or technological aspects). Data were analyzed using an inductive approach. In a first round of open coding, the researcher read through the notes from each observation to identify important concepts and themes in the data. Then, in an iterative process, the researcher returned to the data and reread all of the notes multiple times to discern any previously unrecognized themes, search for disconfirming evidence, refine definition of recurrent themes, and establish reliable codes (Thomas, 2006). Once code definitions were finalized, the data

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Table 1 Demographic characteristics of the sample.

Age in Years ≤ 24 25 – 29 30 – 34 ≥ 35 Race/Ethnicity White Black Asian Latino Relationship Status Married Living with partner On again, off again Never talk Pregnancy Intention∗ Wanted to be pregnant now Wanted to be pregnant later Unsure how I feel about being pregnant Education Some high school High school Some college Completed college Graduate or professional degree Employment Full-time Part-time Unemployed Household Income Per Year <$25,000 $25,000–$49,999 $50,000–$74,999 $75,000–$99,999 $100,000 and greater

Mother (N = 22)

Father (N = 20)

5 8 9 –

2 7 10 1

17 4 2 2

14 4 1 3

13 7 1 1

13 7 – –

16 3 3

13 3 4

1 2 5 9 5

– 3 8 5 4

16 2 4

18 – 2

3 8 4 3 4

1 8 4 3 4

∗ Note: Pregnancy intention item asked participants to respond with reference to how they felt at the time they found out they were pregnant. All participants, including those who had wanted to be pregnant later or were unsure of how they felt at the time they learned they were pregnant, had chosen to continue the pregnancy.

were coded accordingly. Multiple strategies were employed to establish rigor and ensure the credibility of study findings (Noble and Smith, 2015), including searching for similarities and differences across observations to ensure diverse experiences are represented, and consulting with other researchers on study design and across stages of the research process to reduce bias (Long and Johnson, 20 0 0; Morse et al., 20 02; Sandelowski, 1993). Findings Results suggest that interactions with providers may affect the contribution of a prenatal ultrasound to parents’ early imagining of their baby. Sonographers varied widely in the extent to which they initiated or responded to parents’ initiation of conversation that recognized the ultrasound as a relationally significant encounter. Three categories of themes emerged from this analysis: ways in which providers may inhibit, amplify, or influence parents’ mental representations of the baby. One theme in the first category, “failure to engage fathers,” is specific to fathers. Other themes are equally applicable to mothers and fathers, and to observations when the mother was or was not accompanied by the father. Inhibition of parents’ mental representations While some providers treated the ultrasound as both a medical and a relational encounter, others focused exclusively on the medical purpose of evaluating fetal growth and development. When sonographers did not join with parents in acknowledging a dual

opportunity for parents to see and know their baby, their interactions served to inhibit parents’ expression and elaboration of their mental representations. Use of non-inclusive language and practices, a brusque demeanor, and failure to engage fathers, are ways that providers limited opportunity for parents to develop their mental representations. Non-inclusive language and practices Some sonographers used technical language throughout the exam and did not offer clear explanations. When sonographers used unfamiliar terms (e.g., anterior, traverse) without definition, or did not help parents to see the fetus clearly, parents struggled to engage. Both parents entered the appointment seeming excited, and began watching the screen avidly. The sonographer listed the names of body parts and their measurements as she proceeded with the scan, but did not point them out. Ten minutes into the exam, the mother commented to the sonographer, “Wow, you see so many things I don’t see.” The sonographer carried on with measurements and didn’t attempt to help the mother see what she was seeing. The mother kept watching but seemed to lose interest, starting a conversation with her partner about their plans for the evening. By contrast, some sonographers were very good at showing and explaining what they were looking at to parents. When sonographers were deliberate about defining terms and providing accessible metaphors (“what I’m doing now is like taking a belt mea-

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surement”), parents remained engaged with the exam, the sonographer, and each other, talking aloud about their baby, including what they were seeing and what they imagined. General brusqueness When the sonographer’s pace was quick or tone was curt, parents asked fewer questions and made fewer comments to the sonographer or their partner about what they were seeing and how they interpreted it. The parents arrived ten minutes late. The sonographer told them she would focus on measurement, and might not be able to get them good pictures. In telling the parents what to expect from the exam, she said multiple times, “but we’ll see what happens because we’re starting late.” The parents were very quiet throughout the exam. A brusque demeanor seemed to prevent parents from seeking help to make sense of what they saw on the screen and may impede parental efforts to connect with the baby through the exam. Failure to engage fathers Most sonographers welcomed and interacted with both mother and father, but some did little to engage fathers. Lack of engagement ranged from greeting the mother by name and not acknowledging the father who accompanied her, to speaking directly to the mother throughout the exam and not shifting to include the father when offering explanations or inviting questions. Several fathers remarked during the ultrasound that seeing the baby felt especially important to them because they don’t get to feel their baby’s presence as the mother does. Making fathers feel extraneous or excluded may undermine an important bonding opportunity and chance for fathers to develop their mental representations of the baby. Amplification of parents’ mental representations In a variety of ways, providers may support bonding and contribute to parents’ development of mental representations of the baby. Acknowledging or even emphasizing the affiliation between fetus and parents, volunteering relationally oriented comments and questions, and inviting parents’ reflections emerged as important themes that help to explain how some providers reinforce and encourage elaboration of parents’ mental representations. Acknowledging relationships In some of the observed ultrasounds, the sonographer explicitly and repeatedly identified the pregnant woman and her partner as “mom” and “dad” and the fetus as “your baby.” This language had a powerful effect. Parents regularly smiled and reached out to each other upon hearing the question, “are you ready to meet your baby?” When the relationship between parent and fetus was emphasized, parents heightened their attunement to the baby on the screen and the sonographer as she performed the scan. (Note: sonographers at all observed ultrasounds were female, so female pronouns are used throughout.) At about half of the observed ultrasounds, parents learned the baby’s sex for the first time. After determining the sex, some sonographers invoked the relationship, saying for example, “now let’s look at your daughter’s heart.” Parents often responded by noting that this was the first time anyone had ever said “your daughter” or “your son” to them. They seemed moved and proud to hear the words, and often repeated them. Providers’ acknowledgement of relationships appeared to contribute to the emotional significance of the encounter and may foster bonding and parents’ development of prenatal representations.

Social questions Some sonographers asked questions that underscored the fetus as a future member of a family and community. Examples include, “Is this the first grandchild?” “Do any of your friends have girls?” These questions served to socially situate the new baby and elicited parents’ thoughts about their child in the context of their own network of relationships. At times providers asked questions that actively invoked reflection on other important past and current relationships for the parent, for example, “Looks like he’s reaching out for you. Were you a cuddlebug with your mom?” Parents often responded by musing on their own behavior in the context of their relationships, what their child would mean to other important people in their lives, and how the child would fit in. Inviting parents’ reflections on the baby Some providers actively probed parents’ perceptions and expectations about the baby. They asked whether parents thought the baby was a boy or a girl, if they thought the baby would be more like its mother or father, if this was an “easy” or “difficult” baby. Providers also invited reflection by asking parents about perceived resemblances to the fetus. The fetus appeared to be sleeping with an arm flung over her face. The sonographer asked, “Does either one of you sleep like that?” The father replied, “I do,” and the sonographer said, “you’re the instigator!” The father turned to the mother and said, “she sleeps like me!! I wonder what else she’s gonna do like me.” The mother responded by naming some ways she expected their baby to be like him, and teasingly listing ways she hoped their baby would be different. Notably, imagining the baby did not only take place in the mental sphere. On three occasions, fathers were observed attempting to physically replicate the position of the fetus in the womb, in order to better envision the fetus. Sonographers responded by clarifying fetal position and guiding the father in his attempt to physically embody his mental representation of the baby. Influence on parents’ mental representations By offering impressions and interpretations of the fetus, providers may substantively shape parents’ mental representations. Ascribing intention to the fetus and making attributions to fetal behavior, assigning responsibility to the parents for fetal behavior, and suggesting the type of person the fetus is likely to grow to become are ways in which providers were observed to participate in the construction of parents’ mental representations. Attributions to fetal behavior At every observed ultrasound, the sonographer made attributions about fetal behavior. Through these attributions, sonographers suggested fetal autonomy and intention, as well as personality characteristics. It was a consistent occurrence that there were moments when the sonographer couldn’t readily get the view that she needed to take the next measurement. When a sonographer invoked the fetus’s independence or imagined preferences, saying that the fetus “has a mind of her own” or “doesn’t want to be bothered by the paparazzi,” parents expressed curiosity and excitement, imagining aloud what the baby might one day do with her independent spirit. Sonographers alternately described fetuses as “shy”; “content” and “comfortable”, therefore not wanting to move; or “uncooperative” and “difficult”, therefore unwilling to move. These contrasting attributions were significant for parents, who often repeated and implicitly accepted the sonographers’ attributions in discussing the fetus.

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The sonographer said, “the baby doesn’t want to move because she’s comfy right where she is.” The mother laughed and said, “I just love that she’s happy as a clam inside of me.” The sonographer referred to the fetus as “uncooperative” and “stubborn.” The mother responded, “I was afraid this baby would be stubborn because everybody in his family is like that.” The father responded, “It’s true. I guess I’m not surprised this baby is stubborn.” Parents appeared to internalize sonographers’ characterizations of the fetus, suggesting that these characterizations may shape parents’ mental representations of the baby.

Assigning responsibility to parents Not only did providers regularly ascribe agency to the fetus, sometimes they assigned responsibility to parents. “Your job is to tell baby to cooperate. Baby, that’s not where you’re supposed to be. Baby, that’s not what you’re supposed to be doing. You tell baby to move, mom.” Such comments were usually directed specifically to the mother, but occasionally included both parents, as when a sonographer told mother and father that she would take a five minute break for the mother to get up and move around and both parents to “have a talk” with the fetus. When a sonographer spoke critically, describing the fetus as “difficult” and telling the parents to “do something about it,” parents sometimes laughed and sometimes appeared chastened or even apologized. The sonographer issued multiple frustrated comments, e.g., “baby needs to stop moving, tell that baby to stop moving,” and the mother apologized multiple times. One apology referenced the word used earlier by the sonographer to characterize the baby: “I’m sorry he won’t move, he likes to be difficult.” Occasionally, a sonographer embedded the assignment of responsibility in praise for fetus and parent. “All we needed was for you to talk to her! Now everything I need her to do she’s doing. I think you got lucky with this one.” Whether in the context of criticism or praise, assigning responsibility to parents for fetal behavior serves to underscore the connection between parents and fetus and anticipate the responsibility that parents will have and feel for their child’s behavior after birth.

Predicting the future Sometimes, sonographers made suggestions about the implications of current fetal behavior for future behavior after birth. This occurred most often in relation to fetal movement. In the words of one sonographer, “You have a very active little one! I think you’re gonna have your hands full mom & dad!” Parents responded by talking about their excitement or anxiety to have and keep up with an active child. They talked about themselves as children, their current activity level, and their feelings of readiness or unreadiness to parent a highly active child. Sonographers also regularly remarked on specific fetal movements that were reminiscent of specific child and adult activities. For example, seeing a fetus kick, a sonographer said, “Looks like he’ll be a soccer player.” Parents frequently engaged directly with the sonographer’s suggestions of what their future child might turn out to like and do. These reflective responses suggest that sonographers’ predictions may contribute to parents’ imaginings and perhaps impact the timing of parents beginning to imagine their fetus as a baby and beyond.

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Discussion This study used observations of routine 20-week ultrasound examinations to explore how providers contribute to expectant parents’ mental representations of their baby. While the prenatal ultrasound is popularly conceived of as an opportunity for parents to encounter their baby as well as a routine medical screen, results of this study reveal that interactions with providers are also an intrinsic and significant aspect of the prenatal ultrasound. Providers narrate and interpret images for parents and the manner in which they do so may inhibit, amplify, and /or influence parents’ mental representations of the baby. Two factors emerged as influential across thematic areas: (1) parental receptivity at ultrasound, and (2) variability among providers and the power of provider attributions. Parental receptivity Expectant and new parents negotiate significant developmental demands as part of adapting to pregnancy and parenthood. Observed midway through pregnancy at the 20-week ultrasound examination, parents demonstrated great hopefulness and great vulnerability. In conversation with each other and with the sonographer, first-time parents showed interest in imagining their future child and in others’ ideas about who their child might grow to become. They showed receptivity to engaging independently and collaboratively in reflection on their child’s distinct characteristics and ways in which their child might be like and unlike them. The psychological processes of developing a mental representation of the baby and emotional attachment to the baby unfold across pregnancy with variable timing, and the 20-week ultrasound offers an opportunity to observe the state of parents’ thoughts about the baby and the connectedness that parents express and demonstrate toward the fetus. Many parents shared and appeared to grow their mental representation of the baby through their interactions at the ultrasound, linking the images on the screen – and the reflections of others in the room on the images on the screen – to their own imaginings of the baby. When sonographers did not engage with parents’ imaginings and created an environment to quench the expression of imaginings, opportunity to solidify or expand mental representation of the baby was suppressed. When sonographers responded to and amplified parents’ imaginings, their mental representation was reified and perhaps expanded. When sonographers projected their own imagination of the fetus, parents confronted an alternate representation. In general, parents engaged with these alternate representations, repeating and reflecting upon the words of the sonographer and seeking to integrate the sonographer’s representation with their own imaginings of the baby. Essentially, in their interactions at the ultrasound examination, parents-to-be are demonstrating and building their capacity for reflective functioning. In the prenatal context, this manifests in the ability to think of the fetus as a separate person with its own experience, needs, and temperament and think about the relationship that they share and will continue to develop as the child is born and grows (Pajulo et al., 2015). Building capacity for reflective functioning in the prenatal period is critical because prenatal reflective functioning provides a foundation for postnatal reflective functioning and prenatal and postnatal reflective functioning are associated with sensitive caregiving (Arnott and Meins, 2008; Smaling et al., 2016; Steele and Steele, 2008). As a time of psychological reorganization, the transition to parenthood offers a rich opportunity for intervention (Slade et al., 2009). Parents’ capacity and desire to be reflective at the prenatal ultrasound, and receptivity to engaging with others in this endeavor, suggests that prenatal ultrasound presents a fertile setting

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for intervention. Boukydis et al. (2006) have demonstrated that supplementing the routine ultrasound examination with a consultation aimed at increasing maternal interaction with the fetus is associated with greater increase in maternal-fetal attachment than a standard ultrasound examination. Results of the current study, in which mothers and fathers alike demonstrated emerging capacity for reflective functioning and receptivity to engaging in reflection with others, suggest that fathers might benefit similarly from ultrasound consultation. The value of this type of intervention is underscored by research demonstrating the association between prenatal representations and feelings of connection to the fetus and postnatal parenting, parent-child relationships, and child development (Benoit et al., 1997; Huth-Bocks et al., 2004; Siddiqui and Hägglöf, 20 0 0; Muller and Ferketich, 1993). Variability among providers and the power of provider attributions In this study, sonographers showed great variation in the extent to and ways in which they recognized and facilitated the relationship building aspect of prenatal ultrasound. Sonographers inhibited, amplified, and influenced parents’ early mental representations of and feelings of connection to their baby. There was effectively no way to be “neutral” with respect to the relational significance of the encounter. Parents sought to know and connect with the fetus and sonographers who didn’t support or at least acknowledge this had an alienating effect. In most of the observations for this study, sonographers did treat the ultrasound as an emotionally and relationally significant encounter, and sought to engage fathers along with mothers when fathers were present. Yet there was wide variation in whether and how sonographers listened and responded to parents’ reflections and themselves spoke about the fetus as an individual with independent wishes and intentions and personality traits. Some sonographers offered gentle and generic patter to put parents at ease. Some sonographers listened to and advanced parents’ thoughts about the fetus. Some sonographers commented on specific behaviors of the fetus, giving attributions to those behaviors. Some sonographers offered criticism or praise for fetal behavior, and some suggested parents were responsible for fetal behavior. These categories were not mutually exclusive, with most sonographers employing more than one of these approaches during a single ultrasound examination. Parents repeated, engaged with, and often seemed to internalize language used by sonographers, suggesting that the words of providers may have a powerful impact. Both positive and negative attributions imply fetal agency and may serve the purpose of supporting parents’ growing capacity for mentalization. Sonographers and parents themselves at times extrapolated from observations of fetal behavior to predictions for later child behavior, suggesting that attributions may shape parents’ mental representations and expectations into the future. Providers may not be aware of the power they wield, and remarks that they intend lightly may have a weightier impact than they realize. In a time of adjustment, as parents-to-be are preoccupied with making preparations and beginning a relationship with their child (Slade et al., 2009), attributions made by providers about fetal behavior may have a particular salience. Comments that evoke parents’ own families of origin may have unknown and greater than anticipated effect because of how they relate to memories of being a child and being parented that become activated in the prenatal period (Stern, 1995). Sonographers tended to make attributions at moments when the position of the fetus precluded measurement, and parents’ engagement with these comments suggests that even casual remarks by providers may have an impact. At times, they overstated the developmental capacities of the fetus and of the parent to regu-

late fetal behavior. More accurate, in the words of one sonographer, is that “Ultimately there’s no reliable way to get babies to move, I’m at the mercy of babies all day.” Even as they have the potential to support individuation of the fetus through their attributions, providers also have the potential to help or hinder parents’ development of mental representations that accurately reflect the true developmental capacities of the fetus and themselves as parents. Clinical implications With or without intention, providers may contribute to parents’ mental representations and feelings of connection to the baby, yet providers are not typically prepared for or oriented to this aspect of their role as part of standard training. Additional training is warranted for providers (midwives, sonographers, obstetricians) who will perform obstetric ultrasound examinations on how to support early relationship development through sensitive and responsive interaction with parents. In the model of ultrasound consultation developed by Boukydis (2002) for substance-abusing pregnant women, providers are trained to balance listening and actively engaging with parents, emphasize parents’ own perceptions of the fetus and not offer strong interpretations of their own, and represent the true developmental capacities of the fetus. Given the influence wielded by providers in the context of standard care, it would be valuable for all providers to learn and apply such techniques. Findings of the current study suggest additional areas for training and intervention, some very simple. These include acknowledging parents as parents, making effort to engage both parents when both parents are present, and being mindful of language choices. Providers should be sensitized to recognize that even lighthearted comments might be felt deeply by parents given the emotional resonance of encountering the baby through ultrasound, and to particularly attend to the attributions they make at moments when measurement is difficult. In these ways, providers can better meet patients’ psychological and social as well as medical needs. Limitations and future directions This study has several limitations, including the inability to generalize to other populations that is inherent in qualitative research. By design, participants included first-time parents only, all of whom were experiencing a low-risk pregnancy at the time of the 20-week ultrasound. Future research is needed to determine whether providers interact differently with parents in the context of high-risk pregnancies or with those who are not first-time parents, whether these parents engage with and respond to providers differently, and how their needs might differ at the time of the 20week ultrasound examination. This study was cross-sectional; longitudinal research is needed to examine whether providers’ influence on parents’ mental representations is transient or sustained. Despite these limitations, the current study represents an important beginning in understanding how providers contribute to parents’ mental representations of the baby. Better understanding how representations develop during pregnancy, and the sources of influence on those representations, will help inform clinical efforts to promote healthy parental representations and parent-child relationships. Data used in the current study were drawn from a larger investigation focused on parents’ experiences and support needs during pregnancy. As such, no data were collected regarding the providers. However, it is known that all providers involved in observed ultrasounds were female and were registered diagnostic medical sonographers. Future research should address factors that may influence providers’ approach to interaction with parents, including type of professional training, years of experience, personal and professional values and beliefs. Kozhimannil et al. (2015) found

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that women who received midwifery care reported better communication (e.g., they were less likely to report that the provider used words they did not understand, less likely to report holding back questions) than women receiving care from other types of providers, suggesting that parent-provider interactions at ultrasound may vary by the profession of the provider. Research should examine whether providers are consistent across ultrasounds in their interactive style, and whether their style varies depending on who is present (e.g., mother only, mother and father, mother and other accompanying person) or characteristics of those present. Further research is also needed to evaluate the impact on parental representations of additional training for providers of routine ultrasounds to low-risk patients on how to let parents take the lead and be responsive to parental interpretations of fetal behavior. Conclusion The results of this study suggest that for parents who attend a 20-week ultrasound, the process of developing mental representations that is a central task in the transition to parenthood is affected not only by parents’ encounter with the baby on the screen but also by their interactions with a specific provider. The provider’s style, the attributions that she makes about fetal behavior, and her choices to use or not use language that is accessible and that emphasizes the affiliation between parent and fetus have implications for whether parents’ mental representations are inhibited, amplified, or shifted at the ultrasound examination. Empirical and theoretical work has demonstrated the importance of prenatal mental representations and parental-fetal attachment, as well as the possible benefits to maternal-fetal attachment and maternal motivation of enhanced engagement at the 20-week ultrasound. This study suggests the potential inherent in training providers of routine prenatal ultrasounds to better recognize and facilitate mothers’ and fathers’ efforts to develop their own mental representations and establish feelings of connection to the fetus. Ethical approval The study was approved by the Health Sciences Institutional Review Board at University of Wisconsin – Madison. Funding sources This research was supported by the Robert Wood Johnson Foundation Health & Society Scholars Program at University of Wisconsin – Madison. Clinical trial registry and registration number Not applicable. Author contributions “Your baby is so happy, active, uncooperative... How prenatal care providers contribute to parents’ mental representations of the baby” is a single-authored manuscript. Tova Walsh is individually responsible for all aspects of this work. Declaration of Competing Interest None declared. Acknowledgements The author thanks Bethsaida Nieves for assistance with this research, Richard Tolman, Stephanie Robert, John Mullahy and David Kindig for their thoughtful input.

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