It is an incredible honor to be with people in their most vulnerable moments. Standing in solidarity with them and truly wishing for them to have freedom is the ultimate gift we can give. In pregnancy and childbirth, freedom looks like supporting a person to mother on their own terms. Nurse practitioners get to be advocates for those terms during this exceptional time. Being with a pregnant person whose plan is adoption is, in many ways, no different from supporting any other pregnancy and birth experience. In this space, however, many healthcare providers need to stretch in their professional role—continuing to grow their capacity for compassion and keeping their personal opinions and beliefs around the pregnant person’s choices in check. Knowing pregnant people and this work is worthy of our investment.

This article is written from the perspective and experience of two Adoption Assessors from Choice Network, an agency that is dedicated to revolutionizing options and accessibility for pregnant people nationwide. In it, we discuss how nurse practitioners and all healthcare providers can fully honor patients pursuing adoption and ensure optimal outcomes for all involved. To quote our favorite professor and doctor, Monica McLemore, MPH, RN, PhD, “This could all be different.” Let’s make it so.

Three stories

We share the following stories from our experience counseling pregnant people through Choice Network to demonstrate the unintentional harm that can be done when healthcare professionals center their own perspectives over those of their patients and how it could have been different.

Morgan’s story

During her pregnancy, Morgan was struggling with a substance abuse disorder. She had had an open case with her local county agency and had lost custody of her other children. On top of that, she was rarely able to make her prenatal appointments. Staying alive and fighting Children’s Services was all she could manage at times. This struggle is what led her to contact Choice 
Network.

Without warning, Morgan went into labor 6 weeks early. On being admitted, she informed the hospital team that she had an adoption plan, and that she was in the process of matching with a family. After a quick birth, the baby tested positive for drugs. Because she tested positive, Morgan’s nursing team reported her to Children’s Services but neglected to inform them of her adoption plan.

In the meantime, Morgan had contacted Choice Network and officially matched with the family she was hoping for, who began their 5-hour drive to the hospital. Staff were told their estimated time of arrival, which led to plenty of time to coordinate the adoption, because discharge was not to happen until later the following day. Still, nursing staff had expressed concerns that Morgan would not follow through with the adoption plan and that the child would be left without anyone to make medical decisions. Children’s Services used this information when they requested custody of the child in an emergency court hearing later that day, despite both Morgan and her Choice Network advocate assuring them her plan was already in motion.

The child was ultimately placed with Morgan’s chosen family but not for an additional 6 months. The family was met with resistance when trying to visit and communicate with the hospital, leading to 24 hours during which the infant was left alone unnecessarily, Morgan was left reeling, and the family left unsure as to where to turn. After discharge, the baby entered a foster home and Morgan and her chosen family began the fight to get the baby reunified with them.

Children’s Services did not back down in their efforts to take custody of the child. When asked why they pushed this case so quickly to court, they stated it was due to conversations with the nursing team during which it was clear that Morgan could not be trusted.

How could it have been different? The nursing team could have not only made the mandated call as required to do but also provided the full breadth of the plan. They could have simply trusted her.

Naomi’s story

Naomi was a patient of a Crisis Pregnancy Center for months before they referred her to an obstetrics office serving low-income patients that was a 45-minute ride for her by car or a half-day trip on two buses and a train. Despite Naomi missing multiple appointments, and not living near the hospital for labor and birth, the healthcare staff did not help her access more proximate care. Later she learned this was a tactic they used to ensure she was too far gestationally to have an abortion.

On connecting with Choice Network and after deep all options counseling, Naomi was referred for late-term prenatal care one block from where she was living and a hospital in her city. As she began to access prenatal care with more ease, we started working with her new healthcare team and the hospital to establish the adoption plan about which all felt most certain. In her plan, Naomi was very clear in requesting the family be present with her in the hospital at all times and identified one of the adoptive parents as her medical advocate. Due to what she had experienced at the Crisis Pregnancy Center, she felt this was absolutely necessary.

When labor and birth time came, the hospital accommodated her desire for the family to be there, even allowing them to room next to each other. But on the first night, when Naomi sought alone time with her baby, the nurse insisted on being the one to communicate her request to the family. When Naomi was ready to hand the baby back to the family, they were not in their room. When she inquired about their whereabouts she was told by the nurse with a shrug, “They left.” This ignited fear and anger in Naomi as she assumed they had left the hospital because she had not gone to them when, in reality, they had just stepped out for air. By choosing to insert herself between Naomi and her chosen family, this nurse caused unnecessary alarm. Fortunately, everyone was able to rectify the miscommunication before too much damage had been done.

False information and false alarms are pretty common in the healthcare settings for pregnant people, especially those carrying crisis pregnancies. Although these problems may feel small to some, they were crushing to Naomi. She thought healthcare professionals were trusted advocates, but to this day, the only thing she looks back on with grief is not getting the prenatal care she deserved and the huge upset the one night-shift nurse caused her during her precious time with her child and chosen family. It could have been different if she was given accessible prenatal care and the nurse had listened to her.

Imani’s story

Imani, being too far along for abortion and struggling to parent three boys as a single mom, came to us already set on adoption. She was clear from the start that she wanted to be matched with “two moms.” The couple she chose was ecstatic, and the three began building a relationship.

Because Imani was late accessing prenatal care, she knew it might be difficult to find a provider, but her chosen family heard of a place in their shared community that would see her. During their first appointment, however, they realized the provider held religious beliefs that were not in acceptance of all families. With few other options, Imani decided she would let them know she would not allow them to be hateful to her chosen family. She was not prepared for how difficult it would be to enforce this boundary.

During every prenatal appointment and throughout her stay at the hospital, Imani experienced healthcare professionals urging her to talk to another agency and/or consider another family. One afternoon, a nurse spent hours trying to talk her into keeping her baby, asking if she was being pressured and probing into whether her parents and pastor would approve of her decision.

In the end, Imani moved forward with her plan. Post birth, she needed extra time to heal and reevaluate whether she was making this plan for herself, because much of her pregnancy was spent defending the family she loved instead of processing her feelings about the adoption. Healthcare professionals’ unwarranted advice should never have to hold space in a mother’s heart, but the reality is that it does.

How could this be different? By understanding that bias has no space in healthcare.

Adoption: It’s rare and complicated

There has always been a narrative in the United States that adoption is the best and easiest resolution to an unplanned pregnancy. The truth is, adoption is rare and complicated.

Adoption is rare. The Centers for Disease Control and Prevention’s vital and health statistics reveal that only 1% of all pregnant people choose adoption for their babies.¹ The Turnaway Study found that, even when access to abortion is taken from a pregnant person, only 9% will choose adoption.²

Adoption is complicated. Adoption has always been a struggle of those in power, including adoptive families, adoption agencies/attorneys, and systems that police families such as children services agencies and courts, versus those with no power, including pregnant people and birth moms. The world is not built to love on its mothers. Gretchen Sisson, a sociologist who is renowned for her study of abortion and adoption in the US, wrote in the Washington Post after the reversal of Roe v Wade:

“The blithe language of supply and demand deployed by the Supreme Court brings to crude light what has always been true: The market forces that shape adoption do not prioritize reproductive autonomy, support for families or an investment in the best outcomes for vulnerable pregnant women and other pregnant people and their children. Though the Court isn’t responsible for the lack of an adequate safety net, ignoring these realities is yet another way that the Dobbs decision will inflict harm on American women, their families and generations of adopted people.”³

Dorothy Roberts, sociologist, law professor, and social justice advocate, also stated after the Supreme Court decision that “If you don’t see how family separation and forced pregnancy are connected forms of state violence, notice how adoption is being promoted as the ‘solution’ for both.”⁴

Societal oversimplification of adoption as the most honorable solution to an unplanned pregnancy does disservice to both the pregnant person, their child, and our communities. Centering pregnant people throughout the adoption process, no matter what myths we are holding tight as true, requires inner work. We need to weed out any biases that may cause us to replace the pregnant person’s truths with society’s and our own truths.

Centering our patients

Centering our patients means that we are ensuring pregnant people are centered during the implementation of their birth and adoption plans and are the loudest voice in the conversation. Nurse practitioners are in an ideal position to make sure this happens. But how do we know that our patients are making the right choices? Well, we don’t. That is not our job. Dr. Joia Crear-Perry, founder and president of the National Birth Equity Collaborative, recently stated:

“As a descendant of the Enslaved, I believe Self Determination is the most important thing for our Liberation. The movement must provide information and resources for Folks to decide if they want abortions or surrogates; home schools or neighborhood schools.”⁵

It is inappropriate for healthcare professionals to assess, with just a snapshot of information filtered through their personal belief systems, whether a patient is doing the right thing. It can be tempting to assume that a person is making rash decisions in an emotionally volatile situation. However, most people choose adoption after fully considering all their options and investing significant time in selecting a family, all while experiencing the pain and grief of child loss.

Returning to the earlier case studies, we can see that Morgan, Naomi, and Imani experienced trauma during what should have been pretty straightforward adoption experiences, in the care of nurses who were being discriminatory, judgmental, and careless in their communication. Noncentering in their cases looked like rushing to report, disregarding stated adoption plans, pressuring the pregnant person into changing their plan, and intervening in the relationship between a birth mother and her chosen family. Other forms of noncentering (although this is no means an exhaustive list) include withholding information, making decisions about care without consulting the patient, asking leading questions from a position of bias, and bearing silent witness to colleagues doing these things. To reiterate, a healthcare professional’s role is to support patients by creating safe space for them. Trusting pregnant people to know what is best for them and their child should be the default stance.

Honoring all 
options first

Supporting a pregnant person prenatally in accessing all of their choices is essential. Dr. Monica 
McLemore, whose program of research is grounded in reproductive justice, talks often about the fact that no matter your choice, pregnancy ends. Pregnancy ends through miscarriage, abortion, or birth. Once it ends, a person can choose to parent, choose to be a surrogate, or choose adoption.⁶ These are easy ways to assess a person’s true access before pregnancy ends and after:

• 
Abortion: Do they have access to a clinic in their state or a surrounding state? Do they have the funds available, and if not, do they know there are abortion funds they can access? Do they have transportation? Do they have childcare? Can they safely take off work? Does their partner or parent (if they are a minor) support them? Do they need good, solid, trusting referrals?
• Adoption: Do they know they can choose the family, stay in touch with them, and many of their expenses can be paid? Do they know they have a right to be centered in their plan? Do they know this is a decision that can be made after giving birth or any time thereafter that feels right? Do they know that open adoption is the most common form of adoption? Do they know that not all adoption agencies are centered in religious beliefs?
• Parenting: Do they have the support they need prenatally and postnatally as well as insurance, safe housing, reliable transportation, access to food and water, childcare, and essentials to parent their child? If they have an open Children’s Services case, do they need support here? What is the biggest barrier to helping their family stay together?
• Do they know that no matter their choice, they can have a doula present?
•  Are they feeling pressure to choose one option over another by anyone, including people they trust and those they do not?
• 
Are they safe?

Honoring the adoption plan

Supporting a pregnant person to implement their birth plan when they have chosen adoption is just as important as supporting any other birth plan. Helping the pregnant person explore the following questions, without judgment, will empower them during the birthing process and beyond:

• 
How much do they want the adoptive family involved?
• Who do they want to be in the room before, during, and after giving birth?
• Do they want to see or hold the baby? If yes, they should be encouraged to do so.
• 
What do they want to be called? Do they want to name the baby?
• 
Will they breastfeed and will they need a pump or breastfeeding support after the baby is born?
• Do they want to vaccinate and/or circumcise?
• What do they want discharge to look like?
• Do they have a supportive team of professionals surrounding them and are they centered in her plan?
• 
Can they identify who is their safest, most trusted ally in the situation?

In addition to birth plan questions, there are other questions that can be included to walk the pregnant person through feelings following their child’s birth:

• 
How is their body feeling without the baby near them?
• How is the adoption plan going in general?
• Is there anything that could give them peace at this moment?

Interrogating ourselves

It is hard to support the adoption process when we hold personal biases from our own position of power and privilege. Do we want people to mother on their own terms? Do we deem them worthy of our investment? When considering our role, let’s start by asking ourselves some tough questions:

• 
How do I feel about crisis 
pregnancies?
• How do I feel about people who did not or could not 
access prenatal care?
• Do I think teen moms can be good moms?
• Do I think moms with open Children’s Services cases are good moms?
• Do I think children should have two parents?
• Do I support people who have chosen abortion in the past? Do I think there is such a thing as too many abortions?
• 
How do I feel about adoption 
in general?
• Do I support same-sex 
adoptions?
• Do I support transracial 
adoptions?
• 
Do I support incredibly open connections with moms and their chosen families?
• 
Am I okay if a birth father is 
not involved?
• How do I feel when a baby tests positive for substances?
• Do I trust that pregnant people with cognitive impairments can make good decisions?
• Can I consider that systems are not created to support crisis pregnancies?
• 
Can I consider that systems are created to tear families apart?
• 
Can I consider that systems I work in and refer to are full of racist practices?
• Can I consider that I bring my own bias to the client’s I serve?

If on reflection, we realize we have strong feelings about any of these questions, it is our responsibility to interrogate those feelings and educate ourselves further on any triggering topics, so they do not interfere with our ability to do our job. Dorothy Roberts states: “Although these attitudes are not universally held, they influence the way many Americans think about reproduction. Myths are more than made-up stories. They are also firmly held beliefs that represent and attempt to explain what we perceive to be the truth. They can become more credible than reality, holding fast even in the face of airtight statistics and rational arguments to the contrary.”⁷

It is no exaggeration to say that managing our personal values system and held myths is the lynchpin in our ability to support all parties in an adoption plan.

Interrogating our systems

Confirming your healthcare system supports a pregnant person’s choices is another critical way we can serve our patients. Questions to consider:

• What if they are not inclusive of all options?
• 
What if it is truly not safe for a pregnant person to give birth at your hospital?
• 
What if the infant mortality rate is unacceptable?
• 
What if your policies do not support keeping families together, but rather lean toward tearing them apart?
• 
What if they are not inclusive of all families?
• 
What if pregnant people are not trusted?

If we are faced with a system that does not support the goals we have established for our patients, it will be necessary for us to fight to make changes in that system and/or refer our clients to another source of care. Otherwise, the risk to them and their baby is far too high.

Conclusion

Social justice activist Brittany 
Packnett wrote:

“Train yourself toward solidarity and not charity. You are no one’s savior. You are a mutual partner in the pursuit of freedom.”⁸

Nurse practitioners possess great power in the honored space of adoption to help families in the pursuit of their freedom, their terms, and their truth. They hold great power to do it all differently.

Molly A. Rampe is Founder and CEO, and Laura R. Sullivan is COO of Choice Network in Worthington, Ohio. The authors have no actual or potential conflicts of interest in relation to the contents of this article.

Womens Healthcare. 2023;11(2):16-21. doi: 10.51256/WHC042316
© 2023 HealthCom Media. All rights reserved.

References

¹ Vital and Health Statistics: Data from the National Survey of Family Growth. United States: U.S. Department of Health, Education, and Welfare, Public Health Service, Office of Health Research, Statistics, and Technology, National Center for Health Statistics, 2008. https://www.cdc.gov/nchs/data/series/sr_23/sr23_027.pdf.

² Foster DG. The Turnaway Study: Ten Years, a Thousand Women, and the Consequences of Having—or Being Denied—an Abortion. United States: Scribner; 2020. https://www.google.com/books/edition/The_Turnaway_Study/ndToDwAAQBAJ?hl=en&gbpv=1.

³ Sisson G. Alito touted adoption as a silver lining for women denied abortions. Washington Post. July 6, 2022. https://www.washingtonpost.com/made-by-history/2022/07/06/alito-touted-adoption-an-option-women-denied-abortions/.

⁴ Roberts D. 2022. https://twitter.com/dorothyeroberts/status/1542500851360714760.

⁵ Crear-Perry J. 2022. https://twitter.com/doccrearperry/status/1467557505089818627?lang=ar.

⁶ McLemore M. 2020. https://mobile.twitter.com/mclemoremr/status/1301540901295026176.

⁷ Roberts D. Torn Apart: How the Child Welfare System Destroys Black Families – and How Abolition Can Build a Safer World. Basic Books; 2022.

⁸ Packnett B. The Cut: How to spend your privilege. 2018. https://www.thecut.com/2018/08/nia-wilson-spend-your-privilege.html.

Key words: crisis pregnancy, adoption, family, caregiver bias, patient care, pregnant people