Adoption Decision Making among Women Seeking Abortion

Health Care and Adoption Service Experiences of People Who Placed Children for Adoption During Adolescence: A Qualitative Study

STUDY OBJECTIVE

To understand the perspectives of people who placed children for adoption during adolescence DESIGN: We conducted qualitative interviews with adults who placed children for adoption during adolescence. We recruited participants through social media and two adoption-related organizations. We audio-recorded and transcribed interviews. Using thematic analysis, 2 investigators coded the transcripts and identified themes.

SETTING

Telephone interviews PARTICIPANTS: Adults ages 18-35 years old who placed children for adoption before they were 20 years old INTERVENTIONS: Semi-structured telephone interviews MAIN OUTCOME MEASURES: Qualitative data RESULTS: We conducted interviews with 18 individuals (median age of 32 years; range 21-35 years). The median age at pregnancy was 18 years (range 13-19 years). Seventeen participants identified as female and one as nonbinary. Themes included the following: (1) Negative experiences with counseling included limited empowerment to make choices about pregnancy or adoption options; (2) negative experiences with counseling included limited information about practical or financial support for pregnant adolescents; (3) negative experiences with the health care system included insensitivity or lack of awareness of the adoption plan at delivery; (4) positive experiences with counseling included comprehensive unbiased options counseling and adoption counseling emphasizing birth parent choice in openness and family placement; (5) positive experiences included longitudinal emotional support during pregnancy, particularly in ways that normalized adoption placement; and (6) participants desired therapy and/or psychological support following adoption placement.

CONCLUSIONS

Individuals who chose adoption after adolescent pregnancy described positive and negative encounters with health care and adoption professionals that could serve as targets to improve the overall care experience for this population.

"Adoption is just not for me": How abortion patients in Michigan and New Mexico factor adoption into their pregnancy outcome decisions

Objectives

In public discourses in the United States, adoption is often suggested as a less objectionable, equal substitute for abortion, despite this pregnancy outcome occurring much less frequently than the outcomes of abortion and parenting. This qualitative study explores whether and how abortion patients weighed adoption as part of their pregnancy decisions and, for those who did, identifies factors that contributed to their ultimate decision against adoption.

Study design

We interviewed 29 abortion patients from 6 facilities in Michigan and New Mexico in 2015. We conducted a thematic analysis using both deductive and inductive approaches to describe participants' perspectives, preferences, and experiences regarding the consideration of adoption for their pregnancy.

Results

Participants' reasons why adoption was not an appropriate option for their pregnancy were grounded in their ideas of the roles and responsibilities of parenting and fell into three themes. First, participants described continuing the pregnancy and giving birth as inseparable from the decision to parent. Second, choosing adoption would represent an irresponsible abnegation of parental duty. Third, adoption could put their child's safety and well-being at risk.

Conclusions

Adoption was not an equally acceptable substitute for abortion among abortion patients. For them, adoption was a decision that represented taking on, and then abdicating, the role of parent. This made adoption a particularly unsuitable choice for their pregnancy.

Implications

Rhetoric suggesting that adoption is an equal alternative to abortion does not reflect the experiences, preferences, or values of how abortion patients assess what options are appropriate for their pregnancy.

Intimate relationships after receiving versus being denied an abortion: A 5-year prospective study in the United States

CONTEXT

When an individual seeking an abortion cannot obtain one, carrying that pregnancy to term may affect both her relationship with the man involved in the pregnancy and her prospects for new intimate relationships. We aimed to assess the impact of receiving versus being denied a wanted abortion on women's intimate relationships, up to 5 years after seeking an abortion in the United States.

METHODS

Using mixed-effects regression models, we compared relationship outcomes among women who presented for abortion care just under facilities' gestational age limits ("Near-limit abortion patients," n = 452) with those who presented just over, were denied an abortion ("Turnaways," n = 146) at 30 US facilities.

RESULTS

At 1 week post-abortion seeking, the predicted probability of being in a relationship with the man involved in the pregnancy was 58%, gradually declining to 27% at 5 years with no significant differences between those who received and those who were denied an abortion. However, from 2 to 5 years post-abortion seeking, participants who were denied an abortion had double the odds (aOR = 2.01, 95% CI: 1.09-3.69) of being in a poor intimate relationship, with a predicted probability of being in a poor relationship of 14% among those denied an abortion compared with 9% among those who received one (p < 0.05).

CONCLUSIONS

Carrying an unwanted pregnancy to term does not increase the chance of being in an intimate relationship with the man involved in the pregnancy but may have negative implications for the quality of future relationships up to 5 years post-abortion seeking.

Long-term influence of unintended pregnancy on psychological distress: a large sample retrospective cross-sectional study

This study examined the associations between childbirth decisions in women with unintended pregnancies and long-term psychological distress. An online survey of women selected from a representative research panel was conducted in July 2021. Among participants who experienced an unintended pregnancy, the childbirth decision was categorized: (i) wanted birth, (ii) abortion, (iii) adoption, and (iv) unwanted birth. Participants who made childbirth decisions more than 1 year ago were included. ANCOVA was conducted with psychological distress (Kessler 6) as the dependent variable and education, marital status, years from the decision, age of the first pregnancy, economic situation at the unintended pregnancy, and the number of persons consulted at the unintended pregnancy as covariates. Logistic regression analysis was conducted for high distress (K6 ≥ 13) by adjusting the same covariates. A total of 47,401 respondents participated in the study. Women with an experience of unintended pregnancy experienced more than 1 year before the study were analyzed (n = 7162). Psychological distress was the lowest for wanted birth and increased for abortion, adoption, and unwanted birth. In the adjusted model, abortion was associated with lower distress scores than both adoption and unwanted birth. Compared to the wanted birth, adoption and unwanted birth showed significantly higher levels of distress (adjusted odds ratio [aOR] = 2.03 [95% CI 1.36-3.04], aOR = 1.64 [95% CI 1.04-2.58], respectively). Long-term effects on psychological distress differed according to the childbirth decisions in unintended pregnancy. Healthcare professionals should be aware of this hidden effect of unintended pregnancy experience on women's mental health.

Who are the women who relinquish infants for adoption? Domestic adoption and contemporary birth motherhood in the United States

INTRODUCTION

The social context of pregnancy decision-making has changed in recent decades in the United States (US), but little research has examined how these changes manifest in the context of infant adoption.

METHODS

To create an updated profile of US birth mothers, this analysis uses demographic data collected and aggregated from six adoption agencies, with information on 8658 private adoptions that occurred between 2011 and 2020.

RESULTS

Based on this sample, birth mothers today are older and more racially and ethnically diverse than counterparts in previous generations; a majority have other had children and a substantial proportion were parenting other children at the time of relinquishment. They report living on low incomes and, when considered with other measures (e.g., employment, health insurance, homelessness), seem to lack the economic resources that would give them meaningful power over the options available to themselves and their children. Most birth mothers contact agencies late in their pregnancies or after delivery, at a point when abortion care is likely inaccessible or unavailable. An important minority of birth mothers will relinquish more than one infant for adoption over the course of their reproductive lives.

CONCLUSION

Given the underlying shift in the demographic profile of women who relinquish infants, it is likely that the underlying circumstances that lead to adoption have also diverged. More research is needed into how women make decisions about adoption; such research carries implications for how best to support women's decision-making and ensure access to needed services throughout pregnancy and beyond.

Estimating the annual domestic adoption rate and lifetime incidence of infant relinquishment in the United States. Contraception 2021;105:14-18. [PMID: 34418378 DOI: 10.1016/j.contraception.2021.08.008]

OBJECTIVES

Estimating the rate of infant relinquishment for adoption in the United States (U.S.) can inform understandings of pregnancy decision-making and adoption practice. Yet, private domestic adoptions are not systematically tracked. Most methods of estimating adoptions rely on nonmarital birth rates, despite the changing social context of nonmarital births. This analysis provides updated estimates of the rate of infant relinquishment for private domestic adoption in the United States.

STUDY DESIGN

Using data from National Council for Adoption, Centers for Disease Control, and Guttmacher Institute, I compiled annual estimates for the number and rates of births, abortions, and adoptions; calculated annual domestic infant adoption rates among all women and unmarried women of reproductive age; estimated the number of adoptions as a proportion of marital and nonmarital births; and estimated the lifetime incidence of relinquishment for U.S. women.

RESULTS

Since 1982, the annual adoption rate per 1000 U.S. women of reproductive age has been between 0.32 and 0.45, decreasing for the last 30 years. The most recent adoption rate translates to a lifetime relinquishment estimate of 0.9% of U.S. women. Based on patterns from 2002 to 2014, I estimate the current number of private domestic adoptions to be approximately 0.5% the annual number of births, or about 18,300 to 20,000 adoptions per year.

CONCLUSIONS

Despite finding a higher estimate of private domestic adoptions per year than previous estimates, adoption relinquishment rates remain dramatically lower than birth (and thus parenting) and abortion rates in the U.S.

IMPLICATIONS

National and state level information about annual adoptions is needed to inform policies regarding adoption, abortion, and support for families.

Emotions over five years after denial of abortion in the United States: Contextualizing the effects of abortion denial on women's health and lives

BACKGROUND

The Turnaway Study was the first to follow women denied abortions because of state law or facility policy over five years. The study has found negative effects on women's socioeconomic status, physical health, and on their children's wellbeing. However, women did not suffer lasting mental health consequences, prompting questions about the effects of denial on women's emotions.

METHODS

In this mixed methods study, we used quantitative and qualitative interview data from the Turnaway Study to offer insight into these findings. We surveyed 161 women who were denied abortions at 30 facilities across the United States between 2008 and 2010 one week after the abortion denial and semiannually over five years. Mixed-effects regression analyses examined emotions about having been denied the abortion over time. To contextualize the quantitative findings, we draw on in-depth qualitative interviews with 15 participants, conducted in 2014-2015, for their accounts of their emotions and feelings over time.

RESULTS

Survey participants reported both negative and positive emotions about the abortion denial one week after. Emotions became significantly less negative and more positive over their pregnancy and after childbirth. In multivariable models, lower social support, more difficulty deciding to seek abortion, and placing the baby for adoption were associated with reporting more negative emotions. Interviews revealed how, for some, belief in antiabortion narratives contributed to initial positive emotions. Subsequent positive life events and bonding with the child also led to positive retrospective evaluations of the denial.

CONCLUSIONS

Findings of emergent positive emotions about having been denied an abortion suggest that individuals are able to cope emotionally with an abortion denial, although evidence that policies leading to abortion denial cause significant health and socioeconomic harms remains.

To keep or not to keep? Decision making in adolescent pregnancies in Jamestown, Ghana

Background

Jamestown, an urban coastal slum in Accra, Ghana, has one of the highest adolescent pregnancy rates in the country. We sought to understand the decision (to keep or terminate) factors and experiences surrounding adolescent pregnancies.

Methods

Thirty semi-structured indepth interviews were carried out among adolescents (aged 13–19 years) who had been pregnant at least once. Half of these were adolescent mothers and the other half had at least one past experience of induced abortion. A pretested and validated questionnaire to assess the awareness and use of contraception in adolescent participants was also administered. To aid social contextualization, semi-structured in depth interviews were carried out among 23 purposively selected stakeholders.

Results

The main role players in decision making included family, friends, school teachers and the partner, with pregnant adolescents playing the most prominent role. Adolescents showed a high degree of certainty in deciding to either abort or carry pregnancies to term. Interestingly, religious considerations were rarely taken into account. Although almost all adolescents (96.1%) were aware of contraception, none was using any prior to getting pregnant. Of the 15 adolescents who had had abortion experiences, 13 (87.0%) were carried out under unsafe circumstances. The main barriers to accessing safe abortion services included poor awareness of the fairly liberal nature of the Ghanaian abortion law, stigma, high cost and non-harmonization of safe abortion service fees, negative abortion experiences (death and bleeding), and distrust in the health care providers. Adolescents who chose to continue their pregnancies to term were motivated by personal and sociocultural factors.

Conclusion

Decision-making in adolescent pregnancies is influenced by multiple external factors, many of which are modifiable. Despite legal access to services, options for the safe termination of pregnancy or its prevention are not predominantly taken, resulting in a high number of negative experiences and outcomes. Including safe abortion care within the sexual and reproductive health package, could diminish barriers to safe abortion services. Given the vulnerability of the Jamestown setting, a comprehensive sexual education package that addresses the main decision factors is recommended. Interventions aiming to reduce adolescent pregnancy rates should also recognize that adolescent pregnancies are culturally acceptable in some settings, and under certain circumstances, are desired by the adolescents themselves.

Characteristics of Women Who Present for Abortion Beyond the Legal Limit in Flanders, Belgium

CONTEXT

Women who seek abortion care beyond the first trimester of gestation are often in a vulnerable socioeconomic position with limited social support, and in Belgium, the details of their circumstances are insufficiently understood. A better understanding of this group is essential to a critical evaluation of Belgian abortion policy, which restricts abortions on request after the first trimester.

METHODS

Anonymized patient records were collected between 2013 and 2016 from LUNA centers, which are non-hospital-based abortion clinics in Flanders. Logistic regression analyses were used to identify associations between women's characteristics and whether they presented within or beyond the legal limit, which was 13 weeks and 1 day at the time of the study.

RESULTS

A total of 28,741 women requested an abortion, and 972 individuals (3.4%) presented beyond the legal limit; 29% of these latter women were unable to receive abortion care as a result of the mandatory six-day waiting period. Characteristics positively associated with presenting beyond the limit, instead of beforehand, were being younger than 20, as opposed to 20-24 (odds ratio, 1.7); receiving a primary, lower secondary, upper secondary or special-needs education, rather than a higher education (1.8-3.1); being unemployed, rather than employed (1.3); and holding Belgian rather than a foreign nationality (0.8). Being accompanied by someone to the LUNA center (0.8), having irregularly (0.6) or regularly used contraceptives (0.7), and having ever had an abortion (0.8) were negatively associated with presenting beyond, rather than before, the limit.

CONCLUSIONS

A fuller consideration of patients' characteristics when evaluating Belgian abortion policy is needed to ensure that the needs and rights of socioeconomically vulnerable women are addressed.

Attitudes Toward Abortion After Receiving vs. Being Denied an Abortion in the USA

U.S. public attitudes toward abortion have been studied extensively, but little is known about these attitudes among women who seek abortion. This mixed-methods study explores women's attitudes about abortion after receiving or being denied an abortion. Data are from the Turnaway Study, a prospective, longitudinal study of women seeking abortions at 30 U.S. facilities. Participants presented just before a facility's gestational limit and received abortions, or just beyond the limit and were denied abortions. Using mixed effects logistic regression, we assessed 812 participants' attitudes about abortion over four years. At five years after abortion-seeking, we conducted in-depth interviews with 31 participants; this analysis includes the comments of 19 participants who discussed their abortion attitudes in those interviews. We find that six months after abortion-seeking, nearly all women supported abortion legality in all (80%) or some (18%) situations, yet 20% also believed abortion is morally wrong. Women denied an abortion were significantly less likely to support the legal right to abortion at six months (62%) and 4.5 years (77%) after abortion-seeking than women who had received a near-limit abortion (78% and 88%, respectively). In open-ended interviews, women expressed nuanced views, including reporting increased empathy for others facing an unwanted pregnancy. Women's own reproductive experiences impact their views on abortion. Distinguishing between morality and legality of abortion is critical in understanding abortion attitudes.