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recommendations for adoption planning

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

Author(s): Gretchen Sisson, PhD and Rachel Herndon, LCSW

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.


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.


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.  


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.


1. Melina CM, Melina L. The physician’s responsibility in adoption: part 1, caring for the birthmother. J Am Board Fam Pract. 1988;1(1):50-54.

2. Namerow PB, Kalmuss DS, Cushman LF. The determinants of young women’s pregnancy-resolution choices. J Res Adolesc. 1993;3(2):193-215.

3. Namerow PB, Kalmuss D, Cushman nLF. The consequences of placing versus parenting among young unmarried women. Marriage Fam Rev. 1997;25:175-197.

4. Cushman LF, Kalmuss D, Namerow PB. Placing an infant for adoption: the experiences of young birthmothers. Soc Work. 1993;38(3):264-272.

5. Donnelly B, Voydanoff P. Factors associated with releasing for adoption among adolescent mothers. Fam Rel. 1991;40(4):404-410.

6. Bachrach CA, Stolley KS London LA. Relinquishment of premarital births: evidence from national survey data. Fam Plann Perspect. 1992;24(1):27-32, 48.

7. Chandra A, Abma J, Maza P, Bachrach C. Adoption, adoption seeking, and relinquishment for adoption in the United States. Adv Data. 1999;11(306):1-16.

8. Lauderdale JL, Boyle JS. Infant relinquishment through adoption. Image J Nurs Sch. 1994;26(3):213-217.

9. Kaunitz AM, Grimes DA, Kaunitz KK. A physician’s guide to adoption. JAMA. 1987;258(24):3537-3541.

10. Smith S. Safeguarding the Rights and Well-Being of Birthparents. New York, NY: The Evan B. Donaldson Adoption Institute; 2007.

11. Early Growth and Development Study. Agency Report: Birth Parent Summary Statistics from All Sites. 2006.

12. Ge X, Natsuaki MN, Martin DM, et al. Bridging the divide: openness in adoption and postadoption psychosocial adjustment among birth and adoptive parents. J Fam Psychol. 2008;22(4):529-540.

13. Grotevant HD, McRoy RG, Elde CL, Fravel DL. Adoptive family system dynamics: variations by the level of openness in the adoption. Fam Process. 1994;33(2):125-146.

14. Logan J, Smith C. Adoption and direct post-adoption contact. Adoption Fostering. 1999;23(4):58-59.

15. Siegel DH. Open adoption of infants: adoptive parents’ feelings seven years later. Soc Work. 2003;48(3):409-419.

16. Grotevant HD, McRoy RG. The Minnesota/Texas Adoption Research Project: implications of openness in adoption for development and relationship. Appl Devel Sci. 1997;1(4):168-186.

17. Grotevant HD, McRoy RG, Wrobel GM, Ayers-Lopez S. Contact between adoptive and birth families: perspectives from the Minnesota Texas Adoption Research Project. Child Devel Perspect. 2013;7(3):193-198.

18. Monte LM, Ellis RR. Fertility of Women in the United States: 2012. July 2014.

19. Jones RK, Kavanuagh ML. Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstet Gynecol. 2011;117(6):1358-1366.

20. Child Welfare Information Gateway. How many children were adopted in 2007 and 2008? September 2011.

21. Jones RK, Finer LB, Singh S. Characteristics of U.S. Abortion Patients, 2008.

22. Sisson G. “Choosing life”: birth mothers on abortion and reproductive choice. Womens Health Issues. 2015;25(4):349-354.

23. Ellison M. Authoritative knowledge and single women’s unintentional pregnancies, abortions, adoption, and single motherhood: socialstigma and structural violence. Med Anthropol Q. 2003;17(3):322-347.

24. Bryant AG, Levi EE. Abortion misinformation from crisis pregnancy centers in North Carolina. Contraception. 2012;86(6):752-756.

25. Bryant AG, Narasimhan S, Bryant- Comstock K, Levi EE. Crisis pregnancy center websites: information, misinformation, and disinformation. Contraception. 2014;90(6):601-605.

26. Kelly K. In the name of the mother: renegotiating conservative women’s authority in the crisis pregnancy center movement. Signs. 2012;38(1):203-230.

27. Samuels EJ. Time to decide? The laws governing mothers’ consents to the adoption of their newborn infants. Tennessee Law Rev. 2005;72:509-572.

28. Beck MM. Toward a national putative father registry database. Harvard J Law Public Policy. 2002;25(3).

29. Baumann C. Adoptive fathers and birthfathers: a study of attitudes. Child Adolesc Soc Work J. 1999;18(5):373-391.

30. Samuels E. The idea of adoption: an inquiry into the history of adult adoptee access to birth records. Rutgers Law Rev. 2001;53.

31. Samuels E. Legal representation of birth parents and adoptive parents. Adoption Q. 2008;9(4):73-80.

32. Kovalesky A, Flagler S. Child placement issues of women with addictions. J Obstet Gynecol Neonat Nurs. 1997;26(5):585-592.

33. Drabble L, Poole N, Magri R, et al. Conceiving risk, divergent responses: perspectives on the construction of risk of FASD in six countries. Substance Use Misuse. 2011;46(8):943-958.

34. Wong S, Ordean A, Kahan M. SOGC clinical practice guidelines: substance use in pregnancy: no. 256, April 2011. Int J Gynaecol Obstet. 2011;114(2):190-202.

35. Roberts SC, Pies C. Complex calculations: how drug use during pregnancy becomes a barrier to prenatal care. Matern Child Health J. 2011;15(3):333-341.

36. Aloi JA. Nursing the disenfranchised: women who have relinquished an infant for adoption. J Psychiatr Ment Health Nurs. 2009;16:27-31.

37. Foli KJ. Nursing care of the adoption triad. Perspect Psychiatr Care. 2012;48(4):208-217.

38. Gjerdingen DK, Yawn BP. Postpartum depression screening: importance, methods, barriers, and recommendations for practice. J Am Board Fam Med. 2007;20(3):280-288.

39. Henney SM, Ayers-Lopez S, McRoy R, Grotevant HD. Evolution and resolution: birthmothers’ experience of grief and loss at different levels of adoption openness. J Soc Pers Relat. 2007;24(6):875-889.

40. Memarnia N. ‘It felt like it was night all the time’: listening to the experiences of birth mothers whose children have been taken into care or adoption. Adoption Fostering. 2015;39(4):303-317.

41. Gustafson D, ed. Unbecoming Mothers: The Social Production of Maternal Absence. New York, NY: Routledge; 2005.

42. Romanchik B. Being a Birthparent: Finding Our Place. R-Squared Press; 1999.

43. Franklin LC. May the Circle Be Unbroken: An Intimate Journey into the Heart of Adoption. New York, NY: Authors Choice Press; 2005.

44. Weir KN. Developmental, familial, and peer deterrents to adoption placement. Adoption Q. 2000;3(3):25-50.

45. Askren H, Bloom K. Postadoptive reactions of the relinquishing mother: a review. J Obstet Gynecol Neonat Nurs. 1999;28(4):395-400.

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