Tag Archives: adoption planning

My adoption story

Each individual or couple who seeks to adopt a child has a unique story. I chose to share my story in the hope that it might help other nurse practitioners understand the mixture of anticipation, disappoint- ment, joy, and challenges that adoptive families experience. As you see women in your practice who are thinking about adopting a child, are in the midst of adopting a child, or have already adopted a child, know that they will appreciate support from you in their journey.

My family’s journey to adoption began 8 years before my son came home to us on April 27, 2004—a day now celebrated annually in our household as “Gotcha Day” and “Big Sister Day.” However, as in any journey, there were several surprising twists and turns along the way. My husband and I, like many young professionals, had placed our educational and career goals ahead of our goal to have a family one day. By the time we decided that the time was right to start a family, we both had obtained master’s degrees and we both had felt comfortably established in our careers. Then months of trying to become pregnant turned into years, complete with infertility workup, ovulation monitoring, scheduled sex, and multiple attempts at intrauterine insemination (IUI). After the sixth failed IUI attempt, our infertility specialist recommended that we move on to in vitro fertilization (IVF). However, our insurance company at the time wouldn’t pay for the procedure and the cost for one attempt of IVF was roughly equal to the cost of the adoption process. To us, the decision was easy.

We contacted several local adoption agencies, eventually finding one we felt comfortable with, and began our home study process. We wrote letters to prospective birth parents about ourselves and our desire to have a family. We were interviewed together and individually by a social worker who also came to visit and inspect our home. We took classes through a local social service agency to become foster parents, in the hope that we might be able to adopt an infant from the foster care system. After all, in my role as a nurse practitioner (NP), I served on our county’s Child Abuse Response Team (CART), a group of healthcare professionals who make recommendations regarding the health and well-being of children who have been removed from their homes and placed in the foster care system.

We also took advantage of my role as an NP and my contacts in the healthcare professions. On several occasions, we asked colleagues to take copies of our letter to prospective birth parents to national conferences and distribute them to the nurse-midwife and obstetric communities. One of these letters prompted a call from an obstetrician in Texas who herself had been adopted. She had a patient, a young woman, who had just delivered a healthy baby boy and then confided postpartum that she wanted to give the child up for adoption. The obstetrician shared with us that the mother had had little or no prenatal care and no knowledge of the paternal family history, but the child was healthy and beautiful. If we were interested, she wanted to give this little boy the opportunity to live in a stable and loving home that was similar to the one in which she had grown up through adoption.

I started packing while my husband began making flight arrangements to travel to Texas. Several hours later, the obstetrician called us back in tears, reporting that the hospital had intervened. Because we did not have a formalized adoption plan with this woman prior to delivery, we were not eligible to adopt the child. My husband and I were devastated. I cried for days, maybe longer. My husband, family, and friends didn’t know what to do for me. It was several weeks later that we discovered the reason for my severe emotional response; I was pregnant. After our failed IUI attempt, I had just stopped keeping track of ovulation and menses. I was 6 weeks pregnant before I figured it out. Aside from severe hyperemesis gravidarum, I had an uneventful pregnancy and on June 1, 1998, I gave birth to a beautiful baby girl.

Fast forward 6 years. Despite 6 more years of trying to conceive, we were not successful in getting pregnant again. We had moved from Tennessee to New Hampshire to be closer to our families in Maine. We both felt very strongly that we didn’t want to raise our daughter as an only child. We wanted her to have at least one sibling with whom to grow up. Our daughter also kept asking about having a baby brother. We returned to see a reproductive specialist to discuss our infertility problems and again discussed multiple options. Our current health insurance would cover IVF; however, based on my age, our chances of conception with each trial had decreased to 10%-30%.

Again, the decision was easy for us and we searched for another adoption agency and found Vermont Children’s Aid Society. We underwent another home study and had interviews with the social worker, a home inspection, and fingerprinting. We initially decided that we would pursue a domestic adoption, because our social worker had informed us that during the previous year, she had 14 families trying to adopt a child, 7 of which were able to bring home a baby. Once again, the months slowly went by. Our adoption agency was not able to complete a single domestic adoption.

During this period of time, we were required to complete a 1-day training session on adoption through a local social service agency. During the session, we spoke to several families who had adopted a child from Korea and were planning to adopt a second child from Korea. We went home and thoroughly researched Korean adoption. We liked the fact that the children from this country didn’t go into orphanages waiting for adoption but, rather, went to foster care homes where they were the only child in the home under the age of 3. This practice tends to eliminate the risk of reactive attachment disorder and other psychological problems that had been documented extensively in both the medical literature and the lay press as a common experience among children adopted from Eastern European countries.

Our change from domestic to international adoption status meant additional home study work and costs, as well as being fingerprinted by an international agency because the fingerprints we had provided at our local police station would not suffice. The Korean adoption agency also requires adoptive parents to each have a body mass index of 25 or lower because of the strong belief that obese parents raise obese and unhealthy children.

We completed our additional home study work and submitted our application to adopt a child from Korea. We were told that we could expect to have our second child in our home in the next 8-9 months. We were shocked, when, a month later, we received a call from the adoption agency along with pictures of our son! When we had filled out the forms indicating the health problems we were willing to accept in an adoptee, I was quite liberal in terms of my list because I was an NP. I was working for a large tertiary medical center and had access to some of the best medical specialists in our region. Our son’s birth mother had come to prenatal care late in her pregnancy. It was estimated that he was born 8 weeks premature. He weighed 4.4 kg and required blow-by oxygen for 24 hours. He looked perfect to us. He left the hospital after several weeks and went to his foster family.

In addition to our son’s foster mother and father, the foster family included a 21-year-old daughter who was in college but lived at home, a set of 15-year-old twin girls, and a 12-year-old son. They sent us many pictures of our son. We sent them clothes, stuffed animals, and pictures of ourselves. It took 3 months for our son to come home to us. We had decided that we would pay to have an escort bring him to the United States rather than traveling to Korea because this option seemed less disruptive to our family life. We needed to cancel a trip to Disney World that we had planned before we learned that we were going to have to wait only 4 months instead of the 8-9 months that we had originally been told. (Our son’s older sister has never stopped reminding him that his pending arrival at our home caused her to miss the trip to Disney World.) His trip to our home was delayed another 2 weeks because he had been unknowingly exposed to chicken pox.

Finally, the day arrived; we travelled to JFK airport in New York City to pick up our baby boy. It is quite surreal to arrive at JFK’s terminal 4, have an elderly woman disembark from a plane carrying a 6-month-old baby boy, have her place him in your arms, and then, just like that, he is ours. We muddled through the next days and weeks getting to know each other. It was obvious from that first day that he had been well loved and cared for. He was a happy, easy-going baby despite the fact that his world had just been turned upside down. He took it all in stride.

Twelve more “Gotcha Days” have come and gone. We now have a happy, healthy adolescent son—well, as happy as any adolescent boy can be. His childhood has been a classic small-town New England childhood. He loves baseball, plays ice hockey, and is a fearless snowboarder, taking on black diamond runs since the age of 6. He has a bright and inquisitive mind that has challenged both his parents and his teachers. We have  tried to keep him in touch with his Korean heritage. Living in close proximity to a college town, we learned of a Korean Big Brother/Big Sister program. We spent many Sunday afternoons there, learning how to cook Korean foods, play Korean games, and speak some basic Korean words and phrases. More important, our son was able to spend time with other Korean adoptees and Korean college students.

Because I teach at the college medical school, we keep him in touch with his culture through several Korean medical students as well. The students have been gracious and kind to our son. They have brought him gifts from Korea, including games and a building kit of a traditional Korean home. They have also spent time with him and shared their experiences of growing up in Korea. The downside to growing up in our small New England town is that he is one of only three or four kids of Asian heritage in his school. His minority status has been a concern for his father and me, although it wasn’t until he was in sixth grade that another child began bullying him because of his Asian heritage. When the other child called him “slant eyes,” my son initially didn’t realize it was a racial slur. The child’s racial taunting continued until my son told his teacher. The other child was disciplined. but my son didn’t think that the punishment was adequate. He wrote his principal a letter and met with him to advocate for himself and to explain how much the other child’s words had hurt him. We were very proud of the way he handled this situation.

We anticipate continued challenges in the years ahead. Our son is just a few years away from the age that, with our permission, he can find his birth mother. We have always told him we would support him in this endeavor if he chooses to explore it. The adoption agency offers “homecoming tours,” where the Korean adoptees spend 2 weeks in Korea, immerse themselves in Korean culture, and meet their birth families if they choose. We will continue to embrace whatever the years ahead will hold, as we feel blessed to have expanded our family through international adoption.

Maureen Boardman is a family nurse practitioner and Director of Clinical Quality at Little Rivers Health Care, a Federally Qualified Health Center, in Bradford, Vermont. She is also a Clinical Assistant Professor of Community and Family Medicine at Dartmouth College, Geisel School of Medicine, in Hanover, New Hampshire.

Best-practice recommendations for adoption planning and placement in the healthcare setting

Pregnant women considering or planning on adoption present a unique set of needs for healthcare providers who want to support them in their decision-making throughout their pregnancy, delivery, and beyond. Nurse practitioners (NPs) are well situated to provide the nuanced and empathetic care needed. The authors describe the current standard of care regarding adoption planning and placement and provide resources that NPs can use to increase their knowledge about ethical adoption.

Years ago, best-practice recommendations for healthcare providers (HCPs) reflected the realities of closed adoption, wherein birth parents and adoptive parents did not know each other’s identities. For HCPs, closed adoption placed greater emphasis on getting full health histories from the birth parents to pass on to the adoptive parents, and a greater focus on helping birth mothers cope with fully severing contact with their children.1 In the literature, birth mothers were typically described as being young, middle-class, and white, and experiencing their first pregnancy.2-7 Recommendations for these mothers’ care focused on their youth and on the involvement of their parents in their pregnancy and decision-making.2,8 As recently as 30 years ago, it was unusual to offer birth mothers the option of holding their infants after delivery.9

Adoption looks quite different today. Although peer-reviewed research lags behind, survey data and agency reports show that birth mothers have become much more diverse in terms of their racial and  ethnic background, age, and parenting status.10,11 In addition, research shows that open adoption, in which birth parents and adoptive parents have ongoing, meaningful contact before and after the adoption placement, results in better long-term outcomes for members of the adoption triad: birth parents, adoptive parents, and adoptee.12-17 Open adoption has become the preferred and accepted standard in the United States, with 90% of domestic infant adoptions having some degree of openness.10

Healthcare providers, including nurse practitioners (NPs), must be informed about current best practices regarding how to support pregnant women who are considering adoption and birth mothers who have placed a child for adoption. The authors provide recommendations for that standard of care and present resources for NPs who want to continue increasing their knowledge about ethical adoption. These recommendations are drawn from the literature and from the professional expertise of the second author, who has worked with and advocated for more than 500 women in the process of considering, planning, and living their adoptions.

Pregnancy decision-making

Although the pregnancy options of parenting, abortion, and adoption are often presented in parallel, they are undertaken at dramatically different rates. Over the course of their reproductive lives, nearly 85% of pregnant women parent the child,18 30% have an abortion,19 and fewer than 1% place the child for adoption.7,10,20 These percentages do not add up to 100 because these populations are not mutually exclusive. Many women who have abortions are already parenting children, and an even greater proportion will parent a child in the future.21 In addition, many women who place children for adoption will also raise children, suggesting that the diverse circumstances of pregnancy lead the same women to pursue different options at various points in their reproductive lives. Although placement of a child for adoption is rare, NPs should be prepared to handle the situation if a pregnant patient is considering or planning adoption. This preparation includes being ready to discuss all options—parenting, abortion, and adoption— in a productive, unbiased, non-judgmental way.

Parenting

Many pregnant women considering adoption would prefer to parent but feel they lack the resources and support needed.22,23 If a woman wants to parent, NPs should find out what is needed to help her assume that role. She and her child may be entitled to resources such as Medicaid; Women, Infants, and Children (WIC) food nutrition services; support from the child’s father; public childcare vouchers; and/or subsidized housing. Some women may need to address other aspects of their lives to prepare for parenthood (e.g., obtaining addiction treatment, job training, or services for persons leaving abusive relationships). Knowledge of available social services and local non-profit organizations can help these women prepare for parenthood if that is their preference.

Abortion

If a woman is considering abortion but remains unsure, NPs should help her assess her options. Is the pregnancy at a gestational age where abortion is still an option? Does she have an accurate understanding of what the procedure entails? Does she know where to get an abortion? Does she need help in accessing it? Because abortion is far more frequently chosen by pregnant women who do not have the desire, ability, resources, or support to parent at a given point in their lives,19 NPs should be able to provide information about and referrals for abortion care. They should be familiar with local abortion funds that can provide monetary or logistical support. The National Network of Abortion Funds is a good resource.

Ongoing counseling

If a pregnant woman needs further help in making a decision, she should be referred to a counselor or social worker with experience in this area. Backline provides free, unbiased, all-options pregnancy phone lines for callers anywhere in the U.S. who want to discuss pregnancy, parenting, abortion, and adoption. NPs should avoid referring patients to Crisis Pregnancy Centers affiliated with the anti-abortion movement. These centers mislead women, providing them with incorrect information about their pregnancies and misrepresenting the safety and impact of abortion.24-26 This “counseling” does not support all choices and can represent coercion.

Adoption planning

If a pregnant woman is strongly considering adoption or feels it is the right option for her, she must be referred to an ethical adoption agency or attorney. Ethical adoption providers:

offer counseling regarding all pregnancy options;

engage in concurrent adoption and parenting planning during the course of the pregnancy;

actively encourage and support open adoption plans;

have experience working with a diverse range of prospective adoptive families; and

offer post-adoption support to all members of the adoption triad.

These practices help ensure that adoptions are free of coercion and work toward the best long-term outcomes for birth and adoptive families.10 Agencies are generally better equipped than individual attorneys to meet these criteria. However, many adoption attorneys provide ethical legal services and are prepared with referrals for other forms of support. The American Academy of Adoption Attorneys is a good resource for identifying these professionals. NPs should be familiar with at least one adoption provider, either an agency or an attorney, to which or to whom they would feel comfortable referring patients.

The decision to make an adoption plan is considered an ongoing process throughout the pregnancy that should be handled with support and sensitivity. A pregnant woman’s final decision is not made until after delivery, when legal documents terminating her parental rights are signed. Until that point, she is the child’s parent and should be supported as a parent in her decision-making. Of note, a woman should not be lauded as selfless or virtuous because she is considering adoption. She should not be told she is a good mother because of the adoption plan. Her decision should be framed as an attempt to make the best choice for herself at this point in her life.

Legal considerations

A full understanding of the state-by-state legal complexities of adoption is beyond the scope of necessary care. However, the policies surrounding adoption affect how and when parental rights are ended, who is legally eligible to adopt, and which legal rights all participants will have post-adoption, thereby having a great effect on the expectant mother’s experience in planning an adoption. To that extent, and to theextent that they wish to advocate for a patient’s general well-being, NPs should be at least somewhat familiar with their state’s policies regarding adoption. As such, NPs need to consider these questions:27-30

Are open adoption agreements legally enforceable in their state or are they courtesy agreements?

When is the termination of parental rights document signed?

Does the state have an adoption revocation period during which birth parents can change their minds and regain their parental rights?

What are birth fathers’ rights as far as notification and relinquishment?

What is the status of open records? Can adopted persons have access to their original birth certificates, as is considered best practice?

The Child Welfare Information Gateway, a program of the U.S. Department of Health & Human Services, and the American Academy of Adoption Attorneys are good resources to explore for answers to these questions. An expectant mother needs to have her own legal counsel in the process of planning an adoption. She should not have the same lawyer as the prospective adoptive parents because she needs someone who will be advocating for her rights, without any conflict of interest.27-31

Prenatal care

In many ways, prenatal care for women considering adoption does not vary from that for women planning to parent. However, the conditions that make a woman more likely to plan an adoption may make prenatal care more difficult for her to access or more challenging for the NP to provide.

For example, a woman may be considering adoption because she feels ill-equipped to parent because of mental illness, addiction, or other health problems.10,32 For such a woman, particularly one abusing drugs or alcohol, NPs should have a harm-reduction and strengthbased perspective on prenatal substance exposure33,34 so that the woman is not deterred from seeking care.35 Oftentimes, this deterrence is rooted in the double stigma of both addiction and adoption. Yet, even in cases where an infant is born positive for illegal substances and Child Protection Services is contacted, the birth mother has the right to make a safe care plan for her infant, including adoption. NPs should view themselves as patient advocates, affirming that their paramount goal is to achieve healthy outcomes for both mother and infant.

In another scenario, a pregnant woman may be considering adoption because she does not have the support of her family or community. Such a woman may feel ashamed of her pregnancy and the sexual activity it reveals.10 NPs should provide judgment-free care and ongoing support.

The prospective adoptive parents may wish to be involved during the course of prenatal care. They may ask to be present at routine visits or even assume financial responsibility for the expectant mother’s care. They may ask the patient to undergo drug screening, genetic testing, or other healthcare interventions, but the patient is not obliged to honor their requests. NPs need to maintain the expectant mother’s privacy and ensure that any financial assistance does not represent an obligation to place her child with these, or any other, potential parents.10 All of a patient’s health-related privacy rights remain intact.

Labor and childbirth

In preparation for labor and childbirth, an expectant mother planning on adoption needs to have a clear birth plan, and all HCPs working with her must be familiar with the plan. Under ideal circumstances, the expectant mother is supported by a social worker—either from an ethical adoption agency or from the facility where she plans to deliver—in developing a birth plan that meets her needs.

In addition to aspects of labor and childbirth that any expectant mother wants to plan for (e.g., pain management strategies, support persons present), a woman making adoption plans may want to consider these questions:

Who will be in the room during labor and childbirth? Will the prospective adoptive parent(s) be present?

Are there other spaces for adoptive parents at the facility (e.g., another hospital room) where they may wait during labor and spend time with the infant after birth?

When would the birth mother like to invite the prospective adoptive parents to meet the infant?

Are the birth and adoptive parents in agreement on any routine healthcare procedures that the infant may face soon after birth (e.g., vaccinations, circumcision)?

Do the birth and adoptive parents have a plan for the child’s name? Birth mothers sign the original birth certificate and can name the infant, although adoptive parents have the right to re-name the infant once the adoption is finalized and the adoption birth certificate is issued.

Have the birth and adoptive parents discussed whether the infant will be breastfed following birth?

Adoption agencies usually help a pregnant woman navigate and negotiate the answers to these questions. However, some agencies may not provide this help, and private lawyers may not have the expertise or resources necessary to support their clients in this way. In these situations, NPs should be prepared to help their patient think through these scenarios.

A woman planning an adoption can benefit from the support of a birth doula, who can focus entirely on helping her through her birth experience without being especially involved in the adoption planning. NPs should discuss doula care with the patient and be able to provide referrals for compassionate caregivers who can fulfill this role.

Of note, the expectant mother is not only the primary patient but also—along with the birth father, if present—the child’s legal parent until she signs papers relinquishing her parental rights. In most states, this termination of rights cannot occur while she is on hospital grounds.27 Therefore, for the duration of her hospital stay, she is the infant’s parent. From a legal standpoint, she must make all decisions regarding the infant’s care, rooming arrangements, and birth certificate. All providers involved in the birth mother’s care should understand this situation and use respectful language, even if the birth mother allows the adoptive parents to help care for the infant while in the hospital.

Immediate postpartum care

Like all postpartum mothers, birth mothers need support in their physical recovery, with further attention paid to their mental and emotional well-being. Birth mothers experience grief that places them at increased risk for postpartum depression (PPD),36,37 especially because they are already more likely than other postpartum mothers to struggle with mental health problems and trauma histories.10 They should be informed about the range of normal emotional responses, to recognize if they are struggling beyond that threshold, and to know when and where to seek help. Most mothers are screened for PPD at their babies’ well-child visits.38 Because birth mothers will not have this opportunity, they should be screened before discharge, at their own postpartum visits, and at future wellness visits.

Birth mothers need additional support regarding lactation. A birth mother may want to breastfeed while she is with her infant, and should be supported in doing so. In addition, she may intend to supply her infant with expressed breast milk, either before or after the adoption. She should be counseled about pumping and given resources for how to maintain and manage a supply moving forward. However, many birth mothers may not intend to breastfeed, either via nursing or expression, for a substantial amount of time. In these cases, typical efforts to promote breastfeeding in the immediate postpartum setting are inappropriate. These mothers should receive information and support on how to comfortably manage and reduce their milk production in the weeks following birth. The emotional strain of not nursing after adoption warrants supportive care as well.

Some providers go to great lengths to ensure that adoptive parents are included in the infant’s early care. Some hospitals even offer adoptive parents a room to stay in overnight if space permits. Such measures are appropriate as long as they are first respectful to the birth mother’s desires and needs. The novelty of working with excited adoptive parents must never overshadow the careful consideration of a birth mother’s well-being.

The custody plan for the child after discharge should be clear to all parties, including HCPs involved in the care of the mother and the infant. NPs need to make sure that the infant’s health records are transferred to the pediatrician chosen by the adoptive parents, even though the baby’s legal status may be pending. Communication among all HCPs can help ensure continuity of care once all proper releases of information have been signed.

Long-term support

Adoption is a lifelong process, not just for adoptees and adoptive families, but for birth mothers as well. Many birth mothers deal with profound grief after an adoption as they mourn the loss of their parenting relationship with their child.39 Their feelings post-adoption may include sadness, relief, regret, pride, hopefulness, disappointment—the full range of complex human emotions. Some birth mothers report feeling traumatized by the adoption and by the lack of support that they receive throughout and after the adoption process.40 Some birth mothers may feel stigmatized by members of their family, as well as by their community, friends, the media, and even by HCPs.41-44

Such stigmatization may cause them to feel isolated and depressed.

Nurse practitioners should try to provide birth mothers with as much support as they need. Although adoption has changed greatly in the past few decades, the recommendation offered by Askren and Bloom45 in 1999 still holds true: Nurses involved with women at the time of relinquishment can be of significant help in the resolution of grief… Simple recognition of the loss and its significance to the woman will go a long way toward assisting with resolution.

In an ideal situation, the birth mother is further supported by the adoption agency with which she worked. The agency can refer her to individualized counseling with an adoption-competent mental health provider, ensure that she has ongoing support in maintaining an open relationship with her child’s adoptive family, and connect her with a group of other birth mothers with whom she can share her experience.

Some agencies provide some, but not all, of these services; others are unequipped to offer the types of post-adoption support many birth mothers need. Most lawyers who facilitate private adoptions are not able to provide any of these support services—an important reason to refer patients to ethical, full-service agencies during the adoption planning phase, as well as a reason for NPs to be able to make referrals to organizations that can offer post-adoption services.

For a birth mother who needs greater support post-adoption, the American Adoption Congress maintains a list of regional and local support groups on their website. Other organizations that work with birth mothers include the On Your Feet Foundation and Concerned United Birthparents, Inc.  

Conclusion

Despite its comparative rarity in the U.S., adoption, with all its legal and emotional complexity, necessitates that NPs understand how to best address the needs of pregnant women considering it and birth mothers who have chosen it. These situations are usually not medically complicated, but they demand a high level of sensitivity and compassion. When treating a woman who is considering or choosing adoption, NPs need to be able to provide her with a reliable source for nonjudgmental, unbiased pregnancy options counseling; have a working knowledge of their state’s adoption laws; be familiar with an ethical adoption provider; and know how to procure comprehensive post-adoption services. These resources can help ensure the best outcome for birth mothers during pregnancy, childbirth, adoption placement, and beyond.

Gretchen Sisson is a research sociologist at Advancing New Standards in Reproductive Health (ANSIRH) in the Department of Obstetrics, Gynecology, and Reproductive Science at the University of California, San Francisco. She serves on the Board of Directors for Backline. Rachel Herndon is the Director of Birth Parent Services at Adoption Connection, an adoption provider in San Francisco, and she serves on the Board of Directors for the On Your Feet Foundation. The authors state that they do not have a financial interest in or any other relationship with any commercial product named in this article.

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