Words Matter: The Influence of Prenatal Care Experiences on Expecting Parents
Abstract
The words healthcare providers choose during prenatal care not only influence the immediate emotional experience of the expecting parents but also lay the groundwork for a positive parent-child relationship.
On average, pregnant individuals attend at least two ultrasound appointments during their pregnancy, with higher numbers among those with high-risk pregnancies (Siddique et al., 2009). While the medical objectives of the procedure remain consistent across exams, how healthcare providers communicate can significantly impact the patient’s experience.
For example, a pregnant patient attending an ultrasound to assess fetal anatomy may encounter a situation where the ultrasound technician struggles to obtain all the necessary measurements. The technician might sigh and say, “Your baby refuses to stay still. She sure is stubborn!” This is not a hypothetical scenario; these are the words reported by a participant in our research. Such comments can influence an expecting mother’s perception of her baby.
We are concerned that even seemingly innocuous remarks may have lasting effects. In our work, we explore how experiences during prenatal care visits contribute to how pregnant individuals think and feel about their child, even before birth.
Mental Representations of the Child
Infants are completely dependent on their primary caregivers, typically their biological parents.
It is essential to consider how parents think and feel about their children, as these factors influence the quality and quantity of caregiving interactions. Differences in parents’ mental representations of their infants and young children are associated with attachment classification (Benoit, Parker, et al., 1997; Benoit, Zeanah, et al., 1997; Foley & Hughes, 2018; Slade et al., 1999; Zeanah et al., 1994), suggesting that parents’ beliefs affect how their children use them as a safe haven and secure base.
Parents’ mental representations of their children are commonly assessed via the Working Model of the Child Interview (Zeanah et al., 1994), a semi-structured interview that asks caregivers about their child and their relationship with them. While the majority of studies in this area have examined caregiver mental representations postnatally (e.g., Vreeswijk et al., 2012), these representations begin to develop prenatally. Prenatal representations of the child have been linked to later social-emotional functioning. For example, in a sample of pregnant women, non-balanced prenatal representations — characterized by parent disengagement, distraction, role-reversal, or self-involvement — were associated with less secure parent-infant attachment relationships 12 months after birth (Ahlfs-Dunn et al., 2022) and more child social-emotional difficulties two years post-birth (Guyon-Harris et al., 2022), compared to those with balanced prenatal representations who describe and perceive their child in a realistic, nuanced, and emotionally attuned way. Given the possible causal role mental representations play in shaping caregiving relationships and child functioning, it is essential to examine the contributors to these representations during their initial formation.
Previous work has indicated that stress experienced by parents is associated with the quality of parent representations of their baby; higher stress levels relate to less balanced representations (e.g., Huth-Bocks et al., 2004; Malone et al., 2010). Recently, our group examined stress exposure in 298 pregnant individuals. We found that stress experienced during pregnancy was associated with a higher likelihood of having unbalanced prenatal representations (Bailes et al., 2024). Other factors influencing prenatal representations include social support during pregnancy (Pajulo et al., 2001), unplanned pregnancy, and number of prior children (Pajulo et al., 2006). Taken together, these findings suggest that the current context may affect a pregnant person’s representation of their baby. If true, experiences during pregnancy may be fundamental in establishing the initial building blocks of the caregiving relationship.
The Role of Ultrasounds on Prenatal Representations
Those who describe their child, prenatally, as "stubborn" may be mirroring the exact term used by healthcare providers to describe the fetus.
When asked to describe their baby’s personality, many of our pregnant participants repeat the words they heard from their obstetrician or ultrasound technician. These healthcare providers are authority figures with perceived expertise in fetal behavior, making their comments especially influential for patients who are developing their ideas about their baby and their relationship with them.
Prenatal ultrasounds provide the first opportunity for parents to see their baby. The salience of these appointments often strengthens the bond with the baby, making the pregnancy feel more real (Moncrieff et al., 2021; Øyen & Aune, 2016). Ultrasound exams profoundly impact parents allowing them to witness their baby’s movements and receive information that may be exciting, concerning, or even devastating. As a result, prenatal care visits involving ultrasounds are often highly memorable (Awh & Jonides, 2001; Gazzaley & Nobre, 2012; Spence & Parise, 2010).
In an observational study of 22 prenatal ultrasound visits, providers were classified as either inhibiting, amplifying, or influencing their patients’ representations of their baby.
Some providers spoke with curt tones, used medical jargon, and lacked engagement regarding the patient’s evolving bond with their fetus. Other providers emphasized the connection between the patient and their fetus, encouraging them to reflect on their baby’s personality. A third approach involved providers making their interpretations regarding fetal behavior, ranging from attributing autonomy and intention to the fetus (e.g., “Your baby is hiding from me”), to ascribing personality traits (e.g., referring to the baby as “uncooperative” or “shy”). We sought to determine whether providers’ varying comments made during these visits were linked to patients’ mental representations of their babies.
In our longitudinal study of more than 300 pregnant individuals, we interviewed participants in mid-pregnancy to assess their mental representations of their baby. Most descriptions of the child’s personality were positive in tone (e.g., “happy” or “loving”). However, negative descriptors such as “stubborn” or “difficult” stood out. For each description, regardless of tone, we asked, “what made you pick [fill in the blank]?” Midway through data collection, we reviewed our recordings and found that roughly 3 out of 10 participants spontaneously provided a description that they explicitly linked to a prenatal care visit (Hill et al., 2024). After adding the prompt, “Sometimes parents report that the adjectives they use to describe their child’s personality come from their experiences during prenatal exams, like ultrasound exams or prenatal care visits. Do you recall any comments made about your baby in these appointments that really stuck with you?” we found that 7 out of 10 participants reported descriptors originating from comments made during prenatal care visits.
These findings indicate that providers’ narratives are memorable for pregnant individuals. Our analyses revealed that the descriptions from prenatal care visits were nearly three times more likely to be negative than those from any other source (20% vs. 7%). Some of the most common words reported as coming from prenatal care visits were “stubborn” and “uncooperative.” These descriptions remained consistent over time. At a longitudinal follow-up, when infants were 6 months old, participants rated words derived from prenatal care visits as largely accurate in describing their child (M = 7.17, SD = 2.75; Blum et al., 2024). When children were 18 months old, participants with more negative descriptions of their baby during pregnancy reported higher levels of emotional and behavioral problems and more clinical concerns in toddlerhood (Hill et al., 2024).
Recent Findings on the Influence of Language During Prenatal Care Visits
Due to the observational design of our study, we could not determine with certainty whether the type of statements made during those visits influenced participants’ representations of the child.
For example, some individuals may be more likely to remember or incorporate a negative comment into their mental representation. To address ethical concerns and practical limitations regarding negative comments about a baby — fears that such remarks could harm parent-child relationships — we recruited 161 reproductive-age female participants. We asked them to imagine they were undergoing a 20-week anatomy scan for a pregnancy that they intended to keep. All participants watched a video explaining the goals of the ultrasound procedure, followed by a video showing a fetus being measured. In every case, the ultrasound technician could not obtain all the required images, necessitating a repeat visit — a common occurrence in practice.
Participants were randomly assigned to one of three conditions. In one condition, the repeat ultrasound was attributed to technical issues (e.g., “Our ultrasound machine isn’t able to capture some necessary images today. This happens with our equipment sometimes, depending on the baby’s position.”). In a second condition, the technician blamed the fetus (e.g., “Your baby doesn’t want to move how I need them to, and I can’t get them to adjust at all. Your baby is a stubborn one.”). The third condition reframed the need for a repeat scan as an opportunity to connect with the pregnancy and baby (e.g., “You get to come back and spend some more time looking at your beautiful baby.”). After watching the videos, participants were asked to provide five words or phrases to describe the baby’s personality.
Participants in the fetus-blame condition were more likely to use at least one negative descriptor compared to those in the other conditions. Specifically, they were 23 times more likely to use a negative word to describe than those in the connection-focused condition. While we anticipated a difference, the magnitude was greater than expected. Furthermore, participants in the connection-focused condition were more likely to use at least one positive adjective than those in either of the other conditions (Hill et al., 2024). Taken together, this work demonstrates that the way a prenatal care visit is framed — assigning blame versus emphasizing connection — can influence beliefs about a baby, highlighting both risks and potential benefits in how providers communicate during the exams.
Next Steps for Providers
In addition to examining how provider narratives may influence mental representations, we asked all participants, regardless of condition, what they believed healthcare providers should communicate during prenatal ultrasound scans. Responses to this open-ended prompt varied, but two prominent themes emerged.
First, nearly half of the participants expressed a desire to be fully engaged in the process. They advocated for a comprehensive understanding of how the ultrasound worked, what images the providers sought to obtain, and why those images may or may not be captured. One participant noted, “The pregnant patient should be reassured that technical difficulties can occasionally occur, and that the ultrasound technician will try to address the issue or schedule a follow-up scan to ensure a thorough evaluation. If an ultrasound technician is unable to obtain the necessary images of the fetus during a scan, they should communicate professionally and empathetically with the patient.” Another participant suggested that providers should say “something tactful but also honest. If there are concerns they should bring them up but without causing panic.” These responses emphasize the need for professional and clear communication, underscoring the importance of providers engaging with patients, as also noted in the studies reviewed by Moncrieff et al. (2021).
Second, approximately one-third of participants emphasized the importance of reassurance when faced with unclear images, advising providers should communicate that such outcomes do not necessarily indicate issues with the fetus. Echoing the sentiments of Moncrieff and colleagues (2021), many participants felt that providers should comfort expectant parents by assuring them that these situations are common and not necessarily indicative of problems with the pregnancy. For example, one participant suggested that a provider could say, “It isn’t uncommon during these visits for a baby to be in a position that is difficult to photograph. It’s no cause for alarm.”
Participants also expressed discomfort with providers describing the fetus negatively. One participant wrote, “I think they shouldn’t say things like your kid will be a handful or that they’re stubborn. They should not use words or phrases that negatively affect the parents and also the unborn child.” Another argued that “the baby is innocent and has no idea if it’s being difficult or not. Calling it difficult or problematic just causes more stress [for] the mother.” These findings underscore the crucial role of direct, positive communication from ultrasound providers to ensure that pregnant individuals feel informed, reassured, and supported during their prenatal care visits.
Key Takeaways
Our research and studies from other groups provide two crucial insights.
First, the language used by healthcare providers during prenatal care can significantly shape how pregnant individuals perceive their baby, potentially influencing the parent-child relationship and later child outcomes. Negative descriptions of the baby’s personality can lead expecting parents to accept these as true representations of their child, setting up negative expectations. Conversely, words that emphasize the connection with the baby may foster more positive views of that child and the future relationship.
Second, while pregnant individuals value communication during these exams, our research indicates that providers should refrain from stating assumptions about the fetus’s personality. Instead, they should focus on clearly explaining ultrasound procedures and reassuring patients that ambiguous images are a common occurrence and not necessarily indicative of problems.
Consider the participant who recalled that their baby was “stubborn” based on her ultrasound experience. We wonder how her perception might have changed if her provider had said, “We weren’t able to complete the full exam today, which is completely normal with our equipment and happens frequently. On the bright side, you will get another chance for a sneak peek at your baby in a follow-up appointment to complete the exam.” Such a small change could have made her experience more positive and shaped a different view of her child.
In essence, the words healthcare providers choose during prenatal care not only influence the immediate emotional experience of the expecting parents but also lay the groundwork for a positive parent-child relationship. Providers can contribute to positive outcomes for both parents and children by adopting affirming and reassuring language.
Related Resources
References
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Authors
Abigail L. Blum, BA, is a graduate student in the Clinical Science program at Vanderbilt University…
Kaylin Hill, PhD, is an assistant professor in the Psychology Department at the University of Notre…
Kathryn L. Humphreys, PhD, is an associate professor in the Department of Psychology and Human Deve…
