Word count (exclusive of abstract and references): 3495 Acknowledgements: We would like to thank all participants and Vania Sandoz for her help with recruitment. 2 Abstract Background Mental imagery may reflect the present, past or future. Childbirth is often anticipated with joy but also in some cases with fear, which may negatively impact on the childbirth experience. So far, research on birth-related mental imagery in pregnancy is lacking. This study aimed to investigate in detail the

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... nology of spontaneous childbirth-related mental images, and the association between main imagery characteristics (valence, positive/negative percentage ratio, and impact on behaviour and decision-making) and fear of childbirth. Methods A cross-sectional mixed methods design was employed. Thirty-seven nulliparous, Frenchspeaking women, aged ≥18years in their third trimester of pregnancy completed self-report questionnaires assessing fear of childbirth, spontaneous use of mental imagery, prenatal depression, trait anxiety, and participated in a mental imagery interview to assess spontaneous childbirth-related mental images. Women with a prenatal diagnosis of malformation were excluded. Results All participants reported having spontaneous mental images of their impending childbirth. The images captured were rich in detail and included a variety of sensory modalities. More positive mental images were associated with less fear of childbirth (r=-0.533, p=.008) and women who had a higher proportion of negative mental images had a higher fear of childbirth (r=0.428, p=.005). The impact of the most negative mental images on behaviour and decision-making was positively correlated with fear of childbirth (r=0.342, p=.038). Conclusion 3 Results indicate that negative spontaneous imagery around childbirth is associated with fear of childbirth. Intervention techniques could be developed that focus on enhancing positive childbirth-related mental images during pregnancy, counteracting fear of childbirth and fostering a more positive childbirth experience.