Adoption Decision Making among Women Seeking Abortion

Women's Health Issues xxx-xx (2016) 1–9

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Original article

Adoption Decision Making among Women Seeking Abortion Gretchen Sisson, PhD *, Lauren Ralph, PhD, MPH, Heather Gould, MPH, Diana Greene Foster, PhD Advancing New Standards in Reproductive Health (ANSIRH), University of California, San Francisco, San Francisco, California Article history: Received 28 July 2016; Received in revised form 25 October 2016; Accepted 29 November 2016

a b s t r a c t Background: Little is known about how adoption factors into pregnancy decision making, particularly when abortion is unavailable. Methods: We used data from the Turnaway Study, a longitudinal study of 956 women seeking abortion, including 231 women denied abortions owing to gestational limits. Through semiannual quantitative interviews, we assessed the frequency with which women denied abortion considered and choose adoption, and, among adoption participants, decision satisfaction. We compared differences in the demographic profiles of parenting and adoption participants using mixed effects regression models. We conducted in-depth interviews with 31 women who received or were denied wanted abortions, including 2 adoption participants, focused on understanding pregnancy decision making and feelings about their choice. Interviews were coded using inductive and deductive methods. Results: Most women who received abortions were aware of but uninterested in adoption. A minority of women denied abortions (n ¼ 231; 14%) were considering adoption at 1 week after denial. Of participants who gave birth (n ¼ 161), most (91%) chose parenting. Parenting participants (n ¼ 146) did not differ from adoption participants (n ¼ 15) on measures of age, race, or poverty status, although adoption participants were somewhat less likely to be employed (20% vs. 43%; p ¼ .1), and somewhat more likely to have completed high school (87% vs. 74%; p ¼ .08). Although satisfaction with their decision was high among adoption participants, in-depth interviews revealed mixed emotions. Conclusions: Among women motivated to avoid parenthood, as evidenced by abortion seeking, adoption is considered or chosen infrequently. Political promotion of adoption as an alternative to abortion is likely not grounded in the reality of women’s decision making. Ó 2016 Jacobs Institute of Women's Health. Published by Elsevier Inc.

In the United States, 1.1 million pregnancies end in abortion every year (Jones & Jerman, 2014). In contrast, only a small number of womendestimated to be around 14,000 (Monte & Ellis, 2014)dplace their child for infant adoption (Child Welfare Information Gateway, 2011; Smith, 2007). Approximately 30% of women will have an abortion at some point in their reproductive lives (Jones & Kavanuagh, 2011), and a 1999 study indicated that only 1.3% of women (Chandra, Abma, Maza, & Bachrach, 1999) will place an infant for adoption (Chandra, et al., 1999), with agency reporting data suggesting rates of adoption are even lower today (Smith, 2007). These numbers

Funding Statement: This study was supported by research and institutional grants from the Wallace Alexander Gerbode Foundation, the David and Lucile Packard Foundation, the William and Flora Hewlett Foundation, and the Susan Thompson Buffett Foundation. * Correspondence to: Gretchen Sisson, PhD, ANSIRH, 1330 Broadway, Suite 1100, Oakland, CA 94612. Phone: 510-986-8951. E-mail address: [email protected] (G. Sisson).

indicate that, when faced with a pregnancy they do not have either the desire or ability to parent, most American women choose abortion. Indeed, regardless of their familial, educational, racial, and socioeconomic differences, all women are more likely to parent or have an abortion than to place an infant for adoption. Political messaging, however, continues to hold up adoption as a preferred solution for women facing an unwanted pregnancy (Bassett, 2013; March for Life Education and Defense Fund, 2014; Roe v Wade, 1973; The White House, 2012). Such messaging presents adoption as a direct contrast to abortion and often as a solution to the perceived problem of abortion. Yet previous findings suggest this is a false dichotomy: most birth mothers, as women who choose adoption are most frequently called, are uninterested in abortion (Early Growth and Development Study, 2006; Sisson, 2015); and most women seeking abortion are uninterested in adoption (Foster, Gould, Taylor, & Weitz, 2012; Jones, Frohwirth, & Moore, 2008). Those birth mothers who do consider abortion do not weigh it against adoption, but rather consider these options sequentially; they

1049-3867/$ - see front matter Ó 2016 Jacobs Institute of Women's Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2016.11.007

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pursue adoption when abortion is deemed inaccessible or unavailable (Early Growth and Development Study, 2006; Sisson, 2015). This pattern is consistent with broader conceptual models of pregnancy acceptability and decision making, in which decisions are made sequentially based on perceived available options (Aiken, Borrero, Callegari, & Dehlendorf, 2016). Many of the reasons women report for pursuing abortion (Biggs, Gould, & Foster, 2013; Finer, Frohwirth, Dauphinee, Susheela, & Moore, 2005) or adoption (Chandra et al., 1999; Donnelly & Voydanoff, 1991; Krahn & Sullivan, 2015; Namerow, Kalmuss, & Cushman, 1993) suggest that both options can be understood within the context of a constrained choice model (Bird & Rieker, 2008), because legal regulations, community values (e.g., abortion stigma), and social and familial factors (e.g., employment, relationship status, parenting responsibilities, financial well-being) can all powerfully limit the choices that are reasonably available to, or perceived to be available to, individual women during their pregnancy decision making (Biggs, et al., 2013; Chandra, et al., 1999; Donnelly & Voydanoff, 1991; Finer, et al., 2005; Krahn & Sullivan, 2015; Namerow, et al., 1993). An increasing number of regulations on abortion care further limit available options, making abortion increasingly difficult to obtain for many women (Guttmacher Institute, 2015; Jones & Jerman, 2013, 2014; Jones & Kooistra, 2011; Roberts, Fuentes, Kriz, Williams, & Upadhyay, 2015; Roberts, Gould, Kimport, Weitz, & Foster, 2013). Factors such as late recognition of pregnancy, needing time to decide, difficulty finding a provider, and cost lead women to present to abortion care later in their pregnancy than they might otherwise (Foster & Kimport, 2013), leaving them more likely to come up against gestational limits and be denied that abortion care (Upadhyay, Weitz, Jones, Barar, & Foster, 2014). Having been turned away from the abortions they wanted, these women must choose between either becoming a parent or placing a child for adoption. For these women, the options are even more definitively restricted, because their first choice is entirely unavailable to them. This paper explores whether women seeking abortions also consider adoption, and whether women denied abortions pursue adoption when abortion is no longer an available option. Methods This paper uses mixed methods to draw on quantitative and qualitative analyses from the Turnaway Study, a 5-year, longitudinal study of women seeking abortion care at 30 facilities across the United States between 2008 and 2010. The primary aim of the study was to document the health and socioeconomic consequences of receiving versus being denied a wanted abortion; thus, women were purposively recruited into two study groups based on whether they presented just before the clinic’s gestational limit and were able to obtain abortion care, or just after the limit and were unable to access a wanted abortion. A third group of women presenting in the first trimester was also recruited to examine whether the experiences of women having later abortions are comparable with those having abortions in the first trimester. Women were eligible to participate if they had no known fetal anomalies, were English or Spanish speaking, and were aged 15 or older. Researchers conducted semiannual telephone interviews with study participants over the course of 5 years. Women received $50 gift cards after each interview. More details about the Turnaway Study methods are described elsewhere (Dobkin et al., 2014).

In addition to semiannual interviews, in-depth, qualitative telephone interviews were conducted with a subset of Turnaway Study participants between October 2014 and December 2015. The third author of this paper conducted qualitative interviews to elicit information about women’s pregnancy experiences, decision-making processes, and retrospective emotions about their pregnancy outcomes (e.g., abortion, birth), and perceptions about how their pregnancy, abortion or birth affected their lives. Interview subjects were selected randomly from among the sample of participants who had completed the 5-year semiannual interview by October 2014 and had agreed to future contact by the researchers. To supplement the random sample and ensure as much diversity as possible, attempts were made to purposively recruit all former Turnaway Study participants who spoke Spanish as their primary language or who voluntarily placed a baby for adoption after having being turned away and had not been lost to follow-up by the 5-year interview. Recruitment followed a standardized protocol and relied on contact information gathered at the final Turnaway Study interview. Verbal consent was obtained before interviews took place. After the interview, participants were mailed a $50 gift card to a national retailer. Semiannual Interview Measures During a baseline phone interview with research staff conducted 1 week after they originally sought abortion care, women who were denied an abortion and were no longer seeking an abortion elsewhere were asked about their plans for when the baby is born (Tables 1 and 2). Two researchers independently coded responses to this question, and resolved inconsistencies in coding through group discussion (8 ¼ 0.98). The baseline interview also collected information on women’s sociodemographic characteristics, including age, race/ethnicity, parity, educational attainment, income, employment, and relationship status. Finally, the baseline interview asked women to describe reasons why they delayed seeking abortion care and perceptions of social support from friends and family members. At 6-month intervals, women completed a follow-up interview by phone. These interviews included close-ended questions about whether women had considered or chosen adoption. Among those who considered but did not choose adoption, a subsequent open-ended question asked about reasons for not choosing adoption (Table 2). Among those who had chosen adoption, close-ended follow-up questions examined whether it was the right decision for them and how they felt about the adoption. To examine the sociodemographic profile of women considering and choosing adoption, as well as trends in satisfaction in adoption decisions, we used data from six interviews, including the baseline, conducted over 2½ years of follow-up. Semiannual Interview Analysis We assessed bivariate differences in the demographic profile of birth mothers versus women who went on to parent using mixed effects regression models to account for the clustering of participants within facilities. Depending on the characteristic measured, we used either linear or logistic models. All quantitative analyses were conducted using Stata 14.0 (StataCorp, Inc., College Station, TX). Given the lack of data on this topic and the

G. Sisson et al. / Women's Health Issues xxx-xx (2016) 1–9

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Table 1 Baseline Demographic Profile of Women Giving Birth after Being Denied a Wanted Abortion in the Turnaway Study, Overall and by Parenting versus Adoption n ¼ 161

Age Race/ethnicity White African American Hispanic/Latina Other Educational attainment Less than high school High school or GED Some college College degree or higher Union status Married Cohabiting Never married, not cohabiting Previously married, not cohabiting Raising children Living below 100% federal poverty level Yes No Missing data on income Employment Full time Part time Not employed * y z x k

Differences between Birth and Parenting Mothers Birth Mothers, n ¼ 15, n (%)

Parenting Mothers, n ¼ 146, n (%)

p Value*

24 (6.4)y

23.4 (5.5)y

.671 .856

40 54 46 21

(25) (34) (26) (13)

5 4 4 2

(33) (27) (27) (13)

35 50 42 19

(24) (34) (29) (13)

40 55 57 9

(25) (34) (35) (6)

2 (13) 9 (60) 4 (27) 0

38 46 53 9

(26) (32) (36) (6)

16 21 115 9 82

(10) (13) (71) (6) (51)

0 3 (20) 10 (67) 2 (13) 7 (47)

16 18 105 7 75

(11) (12) (72) (5) (51)

41 (25) 55 (34) 65 (40)

1 (7) 8 (53) 6 (40)

47 (32) 40 (27) 59 (40)

36 (22) 29 (18) 96 (60)

0 3 (20) 12 (80)

36 (25) 26 (18) 84 (57)

.081x

.772z

.822 .184

.104k

Given clustering of participants by clinic, differences were assessed using mixed effects regression and postestimation permutation tests. Median (standard error). Given 0 cell, differences assessed by collapsing into dichotomous married/cohabitating vs. not. Given 0 cell, differences assessed by collapsing into three part variable: less than high school, high school or GED, some college or higher. Given 0 cell, differences assessed by collapsing into dichotomous any employment versus unemployed.

overall rarity of choosing adoption, we use a p value of .10 as our threshold for significance. In-Depth Qualitative Interview Measures In-depth qualitative interviews were open-ended and ranged from 30 minutes to 2 hours. Questions elicited participants’ accounts of their pregnancy-related experiences and emotions when they first discovered they were pregnant with the index pregnancy, when they had an abortion or were turned away, and in the 5 years since initial recruitment. Participants spoke about the circumstances surrounding the index pregnancy, the pregnancy options they considered at the time, their relationship with the man involved in the pregnancy, and important life events or changes that have occurred in the intervening years related to school, work, family, and relationships. Participants were also asked to share their perceptions of how their experiences with the index pregnancy, abortion, birth, parenting, or adoption have affected their lives. All interviews were audiorecorded, transcribed, and translated if necessary. In-Depth Qualitative Interview Analysis The third co-author coded the transcripts for themes in Atlas.ti 7 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) using inductive and deductive coding techniques. Initial codes were developed using three randomly selected transcripts and were double-coded by two researchers until all codes were reconciled. This analysis uses codes related to adoption consideration or placement. The first author used modified grounded theory (Charmaz, 2006) to identify emergent

themes from this code, particularly themes relevant to considering, ruling out, or choosing adoption and feelings about the adoption experience. All research activities were approved by the local institutional review board. Results Samples The sample for semiannual interviews included 956 women, 231 of whom were denied a wanted abortion, including 161 who went on to give birth (Figure 1). Of those that gave birth, 15 placed the infant for adoption. The sample for in-depth interviews included 31 women: 16 who received abortions and 15 who were turned away and did not receive abortions elsewhere. This sample included 28 randomly selected participants and 3 purposively selected participants, including 1 Spanish speaker and 2 women who placed for adoption. The majority of participants (77%) who were reached by phone and informed about the study chose to participate. The nine women who did not participate after being informed about the study expressed interest initially but did not follow through with an interview, despite repeated attempts to reschedule. Fourteen additional women selected to participate did not respond to any contact attempts, most likely owing to incorrect contact information or lack of interest. Adoption Consideration while Seeking Abortion We are able to use the in-depth qualitative interview data from the 16 women in the abortion sample who sought and

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Table 2 Summary of Quantitative and Qualitative Measures Measure

Participants Asked (n)

Considering/Placing for Adoption (n)

Adoption Consideration at Baseline (Wave 1): One week after being denied abortion care, participants in the Turnaway Group who reported that they were not still seeking an abortion were asked the open-ended question “Do you have an idea of what you will do when baby is born?” If necessary, women were prompted for a response with the following: “Do you think you will raise it, arrange for it to be raised by an adoptive family, or have someone you know raise it?” Participants who were still seeking an abortion were coded as not considering adoption at that point in time.*

171

24

Adoption Consideration (Wave 2 Interview): Six months after being denied abortion care, Turnaway Study participants who gave birth were asked, “Did you consider putting the baby up for adoption?”y

144

37

Adoption Placement: Participants in the Turnaway Group who gave birth and participated in any subsequent interviews were coded for whether or not they placed their infant for adoption.

161

15

Adoption Dismissal (Wave 2 Interview): Participants who reported adoption consideration but not placement at Wave 2 were asked, “What made you change your mind?”

22

NA

Adoption Confidence: At each subsequent wave of interviews (6, 12, 18, 24, and 30 months after being denied their abortions), the women who placed the infants for adoption were asked, 1) “At this point how do you feel about putting the baby up for adoption?”, 2) “Given your situation, was the decision to arrange an adoption the right one for you?”, and 3) “How often do you think about the pregnancy or baby?”

Wave Wave Wave Wave Wave

In-depth Qualitative Interviews: All in-depth qualitative interview participants were asked how they thought about their pregnancy options before either accessing or being denied abortion care. The two in-depth interview participants who placed infants for adoption were also asked about their feelings around the adoption when it occurred and over time.

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2: 3: 4: 5: 6:

15 12 11 11 9

NA

Consideredz: 6 Placed: 2 Not askedx: 2

Not including 11 participants who failed to give a meaningful answer. Not including three participants who were still pregnant at the time of the Wave 2 interview. z Not including those who placed. x Two participants were not asked about adoption consideration, one because she experienced a fetal loss, the other because she was seeking an abortion for health reasons. * y

received abortions to assess the extent to which these women considered adoption while they still had the option of getting an abortion. Retrospectively, none of these women reported that adoption was an option they were interested in. When asked, many simply said, “That thought never really entered my mind,” or “I just instantly went to abortion.” This did not mean that women were ignorant of adoption as a choicedseveral mentioned considering it in passing, and dismissing it quickly. Adoption was often ruled out because they felt it was not right for them, because their partner would not be interested, because they had health reasons for not wanting to carry to term, or because they believed there were already enough children in need of homes. In one case, Wendy, a 32-year-old married mother of one, had made an adoption plan during a previous pregnancy, which informed her and her husband’s experience in this pregnancy: [In the earlier pregnancy], we had picked out a family. She actually went there for about two weeks until we changed our mind..We thought, you know, if we couldn’t give her the life that she deserved then we’ll give somebody else the opportunity to.I tried to separate the post-partum blues from my own emotions. And then I just realized like it’s not postpartum. This is our child..We need to get her back and raise her even if we have to struggle or we have to sacrifice different things, we’ll make it work..So, we got her back. So [with this pregnancy] we already knew what the options were. We already knew that adoption wasn’t going to work. That just wasn’t in our blood. In this case, as in many others, women ruled out adoption because abortion represented their preferred solution, not because they were unaware that adoption was an available

choice. It was simply not a choice they were interested in pursuing when abortion was available to them. Several women who did receive an abortion also stressed that, had they not been able to access their abortions, they still would not have pursued adoption. As one participant said, “If I had given birth .no. I would never give it up for adoption. I wouldn’t let it leave my sight.” Latishia, a 26-year-old single mother, expanded: I was like if I feel like if I’m going to go full term then I was just prefer to just keep it. I don’t want to have to know that I had a child out here in the world or whatever that I done gave my baby away. No. I would just eitherdI just felt either more comfortable with terminating it or just keeping it. I was not even going to do adoption. It’s not an option for me. These responses reiterate that, for most participants, the choice they were making came down to whether to have an abortion or give birth and parent the baby, with adoption being the choice they least preferred in their decision-making process. Adoption Consideration after Denial of Abortion The semiannual interview data show that, 1 week after being denied a wanted abortion, 24 of 171 women (14%) reported that they had plans to place the baby for adoption, or were considering it as an option (Table 2). Ultimately, of the 161 women who gave birth, 15 (9%) placed their child for adoption. The vast majority of women denied an abortion did not pursue adoption, and went on to parent their child. Of the 15 participants who placed a child for adoption, 12 (80%) reported considering adoption in the interview 1 week

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Figure 1. Consideration of adoption and pregnancy outcomes among women seeking abortion in the Turnaway Study who were initially denied care.

after being denied an abortion. An additional two birth mothers were still seeking an abortion 1 week after denial; thus, we assume that they were not leaning toward adoption at that point. This finding suggests that most birth mothers in the Turnaway sample considered adoption very quickly after accepting they would not be able to access an abortion at that facility or possibly any facility. However, adoption consideration 1 week after denial did not mean women were likely to place for adoption; only onehalf of the 24 women (50%) considering adoption at 1 week ultimately made that choice.

Choosing Parenting after Being Denied an Abortion Among the women denied abortions in the Turnaway Study, the majority chose to parent. Of the 146 participants parenting, 26 (18%) reported considering adoption at either 1 week or 6 months after their abortion denial. Thus, although the majority of women never considered adoption beyond dismissing it fairly quickly, even among the 37 participants who reported, 6 months after their abortion denial, having considered adoption to a meaningful extent, most (64%) chose to parent. In open-ended questions about adoption dismissal, three reasons emerged for why women denied abortions would ultimately decide to parent over placing for adoption. The first reason, expressed by several women, reported finding greater partner or familial support than they had expected; one participant said, “my family, and the guy that I was with nowdthey said they would help,” and another responded that “the amount of help that I got from both families” made impending parenthood seem more manageable. In her interview, Monique, an in-depth interview participant, expanded on this theme. Monique was a 30-year-old single mother, working two jobs to make ends meet. After being denied an abortion and having a temporary care arrangement fall through, she found that her family willingly offered more support than she had expected:

Once people realized that I was going to have the baby, believe it or not, they got more supportive, which was amazing to me, because I always thought it was going to be the opposite.But once I really came out and told them the process of which I had just been through, and what I tried to do [have an abortion], that’s when they became very supportive. The second reason women denied abortions reported deciding against adoption was the bond they felt with their child after birth. One woman ruled out adoption “as soon as I saw [the baby],” another described her feelings toward her daughter: “She’s so adorable. I had too many feelings for her to give [her] to someone I barely knew.” After meeting their children, adoption became unimaginable for these women. The third reason had to do with attitudes about parenting and adoption. Some participants responded that they would feel guilty if they placed the child for adoption, either because they believed adoption was an abjuration of responsibility, or because they believed it meant they’d have no ongoing knowledge of their child: “Couldn’t bring myself to do it. I would have a child in this world that I would know nothing about.” Again, in-depth interviews described this sense of obligation in more detail. Michelle, a 27-year-old married mother of two, explained: We went through the whole ‘maybe we should give the baby up for adoption.’ I couldn’t do it. There’s no way that I would be able to carry a baby that long and then give it away knowing that I have two other children at home .and then have that kid maybe come back one day and say, “Why didn’t you want to take care of me?” I couldn’t do it. These women cite feelings of maternal bonding and prevailing parental responsibility, and draw on increased social support from their partners and families, as factors that contributed to their decision to parent in favor of adoption.

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Choosing Adoption after Being Denied Abortion The two participants who completed in-depth interviews and who placed an infant for adoption provided insight into why participants chose adoption after being denied abortion care. Maria was 19 years old when she learned she was pregnant at 5 months gestation. At first she was excited about her pregnancy, but that excitement was fleeting: “My 2 minutes of happiness that I first felt drifted away slowly when I started realizing that bringing a kid into this world was a lot harder than I thought it would be.” Fearful that her family would “turn their backs” on her, and with her partner not providing support, Maria felt that she did not have the support needed to parent. After feeling “devastated” when she could not get an abortion, she said: “I knew [adoption] was the best and only option that I had.” Emily was a 19-year-old recent high school graduate who was turned away from three clinics before resigning herself to continuing her pregnancy. Noting her limited financial resources and unhealthy relationship with the man involved in the pregnancy, Emily felt she was not well-suited to parent at that time. “I just knew that I couldn’tdthat I wouldn’t be able to support her and have her experience life in the way that I would like her to, and I knew that there were options that would give her that.” Whereas previous participants cited maternal obligation as a reason for parenting, Emily draws on a similar maternal desire to give her daughter a better life than she can provide as a reason for adoption. Still, she frames this choice as secondary to her desire for an abortion: “If I couldn’t have an abortion, okay, then I would definitely be doing open adoption.” In addition to highlighting the constraint placed on her choice because she cannot obtain an abortion, with this statement, Emily reiterates her desire to avoid parenthood. For both Maria and Emily, then, adoption becomes a solution to their abortion denials in a way that it does not for women who express a desire or obligation to parent as their pregnancies continue. Comparing Parenting Mothers and Birth Mothers Participants from the Turnaway Group who parented did not differ from participants who placed for adoption in terms of their age, race and ethnicity, participants’ mothers’ educational level, poverty status, parity, union status, and parenting status of previous children. However, compared with parenting mothers, birth mothers were more likely to have a high school education or more (87% vs. 74%; p ¼ .08), and less likely to be employed than parenting mothers (20% vs. 43%; p ¼ .10). Additionally, birth mothers were also less likely to report “trouble deciding what to do” as a reason for delay in seeking abortion (17% vs. 45%; p ¼ .07). Decisional Confidence and Satisfaction with Adoption Overall, birth mothers in the Turnaway Study sample were very confident that placing their infant for adoption was the right decision for them. At 6 months after being turned away for an abortion, all birth mothers reported that adoption was the right decision. This belief continued over the subsequent 2 years. At 12 months, 11 of the 12 women interviewed indicated it was the right decision; at 18 months, 10 of the 11 women indicated that it was the right decision. However, at 24 and 30 months, all women interviewed indicated it was the right decision, including the one participant who had indicated otherwise in previous interviews.

Similarly, when asked how they felt about putting the baby up for adoption 6 months after being denied abortion care, 87% reported feeling “very” or “somewhat” happy. The majority of women (10 of 13) reported stable levels of happiness over 2.5 years of follow-up. Three reported changes in happiness, including one who reported a decrease (from very happy to somewhat unhappy), one who reported an increase (from very unhappy to somewhat happy), and one who reported both increases and decreases. These overall high levels of satisfaction were further reflected in the in-depth interviews with both Maria and Emily, the two birth mothers who were included in the qualitative interview sample. As Maria describes: I’m happy that I went through this. I felt like it’s the best decision I’ve ever made because I look at the pictures that the adoptive parents send me, and she’s very healthy. She’s very happy. And seeing her happy makes me happy because at that moment I knew I wasn’t going to be able to make her happy the way they’re doing it. Emily similarly described her adoption as a “really, really good situation,” concluding that she “just got lucky” and that her daughter’s life is “way better than what I could have offered her.” However, both birth mothers also expressed more complexity to these emotions. Despite having an open adoption, Maria kept the adoption secret from nearly everyone in her life, including from the child’s birth father, and she does not have contact directly with her child. While she states that adoption is “the best decision [she’s] ever made,” she also comments on this secrecy: “It’s still something that I can’t talk about with anybody.It really did mess me up in a way emotionally because I just didn’t know how to respond to it.” Emily expressed a similar range of emotions around her adoption: I think I will pretty much always doubt whether my choice was the right choice or whether I should have chosen something else. I think that will always kind of be with me, not for my own decision, because for myself I just want to think it’s right thing to be able to still experience life and still experience her life. But I more think of it for her.I think I will always, and do always, doubt whether that was the right decision, and what will happen to my daughter. But at the time, I think I still had that mentality of this is what I’m choosing. I have to be 100% about this decision. These in-depth interviews suggest a greater range of satisfaction and emotional outcomes than are reflected in the generally high levels of happiness reported in the semiannual interviews. Both Maria and Emily became pregnant again during the course of the 5-year Turnaway Study. Maria, who expressed a desire but felt unable to parent before her adoption, is raising her second child. Emily, who went to three abortion clinics and was adamant about avoiding parenthood with her earlier pregnancy, had an abortion. Discussion This analysis reveals that, among women who are highly motivated to avoid parenthood (as indicated by their abortion seeking), adoption was most frequently understood as the least preferred option. This was true even when abortion was no longer an available choice: the vast majority of women (91%) denied abortion care chose to parent, rather than to place their

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child for adoption. As indicated by low rates of adoption consideration and adoption choice, these new findings suggest that most women pursuing abortion are not interested in adoption, as is consistent with previous research (Foster, et al., 2012). When considered with earlier studies indicating that most birth mothers do not seriously consider abortion (Early Growth and Development Study, 2006; Sisson, 2015), it seems, the primary alternative to either abortion or adoption is parenting: many birth mothers hope to parent, and place for adoption when their parenting plans are thwarted (Krahn & Sullivan, 2015; Sisson, 2015); many women seeking abortions choose parenting, rather than adoption, when their access to abortion is denied. Not only are few women choosing between abortion and adoption at any point in their pregnancy (Jones, et al., 2008; Sisson, 2015), but most birth mothers only choose adoption when their first plandeither parenting or abortiondis no longer legally or logistically possible. The fact that 9% of Turnaway participants did choose adoption, when only an estimated 1% (Chandra, et al., 1999) of women will do so over the course of their reproductive lives, further supports the idea that adoption is chosen more frequently when there are fewer real or perceived options available. These results also suggest that women who choose either adoption or parenting after abortion denial are very demographically similardmore similar than previous research comparing birth mothers and parenting mothers has found the two groups to be (Bachrach, Stolley, & London, 1992; Donnelly & Voydanoff, 1991; Ellison, 2003; Namerow, et al., 1993; Namerow, Kalmuss, & Cushman, 1997). Although our finding that Turnaway birth mothers were more likely to have completed high school than their parenting counterparts is consistent with earlier studies (Bachrach, et al., 1992), that was the only demographic pattern that we found that was consistent with previous research (Bachrach, et al., 1992; Donnelly & Voydanoff, 1991). For example, studies have found that, compared with their parenting counterparts, birth mothers are more likely to have collegeeducated, never divorced, high-income parents, suggesting a higher socioeconomic status (Namerow et al., 1993, 1997). In contrast, we did not find a difference in participants’ parents’ education between Turnaway participants who chose parenting and Turnaway participants who chose adoption, nor did we observe a difference in poverty status. The only indication of difference in socioeconomic status that we found was in employment: birth mothers were less likely to be employed full time than parenting mothers. This difference might contribute to a sense of comparative ill-preparedness to parent that has been found in prior studies (Sisson, 2015). Additionally, whereas birth mothers are (Ge et al., 2008), and have historically been, predominantly White (Miller & Coyl, 2000; Moore & Davidson, 2002; Moss, Snyder, & Lin, 2015)dwith virtually zero percent of children born to Black women being placed for adoption in the mid-1990s (Chandra, et al., 1999)dwe found no difference in race for Turnaway participants who parented compared with those who placed. These differences between our results and previous findings can be interpreted in two ways: first, most demographic studies of birth mothers are older and possibly outdated, although the most recent study indicates the racial and ethnic demographic characteristics are changing (Ge, et al., 2008); the limited amount of recent research make it impossible to know the extent to which the overall characteristics of birth mothers have changed, or whether Turnaway birth mothers are substantially different from the broader population of all birth mothers. Second, and more important, most previous

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research on birth mothers compares them with women who parent, although most women who parent do not try to obtain an abortion for that pregnancy. The fact that all of our participants pursued abortion, then, makes them more similar than different, regardless of whether they choose parenting or adoption after being denied abortion care. This suggests that women who pursue adoption after being denied an abortion might be qualitatively different from women who pursue adoption having never wanted an abortion; future research might explore the different trajectories that lead women to place infants for adoption. Finally, given that only 15 women chose adoption in this study, we have limited power to detect small differences in the profile of women who adopt, in comparison to those who parent. Lastly, the participants in our sample seem to feel more positively about their adoption than do other birth mothers. Many birth mothers express some grief, ambivalence, or unhappiness with their adoption (Christian, McRoy, Grotevant, & Bryant, 1997; Fravel, McRoy, & Grotevant, 2000; Grotevant & McRoy, 1997; Henney, Ayers-Lopez, McRoy, & Grotevant, 2007; Sisson, 2015). The Turnaway Study birth mothers’ levels of happiness with their adoption, assessed through semiannual interviews, are notably high. In this way, they were similar to participants who obtained abortions, the vast majority of whom reported that abortion was the right decision (Rocca, Kimport, Gould, & Foster, 2013; Rocca et al., 2015). However, the indepth interviews with birth mothers reveal a greater range of complex emotional responses around adoption, suggesting that the semiannual interviews may not have captured this nuance for other birth mother participants. An additional explanation for this difference is that most birth mothers report that they would prefer to parent (Sisson, 2015), and only pursue adoption when parenting becomes impossible. This contrasts with birth mothers in the Turnaway Study, who, based on their abortion seeking, we might infer either felt unprepared for parenthood at one point their pregnancies, or had little or no desire to parent at any point in their pregnancies. For these women, adoption represents a contingency solution; for most birth mothers who would prefer to parent, adoption represents a failure to assume the parenting role they desire. Their differences in retrospective satisfaction, then, understandably differ. Future research should explore whether and how this satisfaction changes over time, for both groups of birth mothers. This analysis is limited by the relatively small number of birth mothers in the sample. Given the rarity with which adoption is chosen, this demonstrates an ongoing challenge in researching birth mothers. Additional analyses performed on larger datasets would allow for more conservative significance levels to be used. More recent data on the rates of domestic adoption placement and the demographic makeup of birth mothers is needed to provide the most accurate context within which women are choosing adoption and under what circumstances. Another limitation is our reliance on retrospective assessment; participants who were able to get abortions were only asked if they had considered adoption after they were no longer pregnant; their responses might have been different had they been asked earlier. Additionally, the semiannual participants who were able to obtain an abortion without ever being turned away were not asked whether or to what extent they had considered adoption. However, given that the in-depth interview participants who were never turned away show consistently little interest in or consideration of adoption, and earlier studies indicating an extremely low interest in adoption among women seeking

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abortion (Foster, et al., 2012), we might infer that this is reflective of the larger group. Finally, this research specificallydand the discussion of pregnancy decision making more broadlydis limited by varied understandings of what it means to “consider” any one option. Consideration might involve a being aware of an option, but dismissing it quickly; it might involve more in-depth contemplation or even personal research into what that choice entails. When women report considering adoption, we do not know to what extent they did, or even how meaningful that consideration was to their pregnancy decision making. More research is needed on the topic of adoption, birth motherhood, and pregnancy decision making to better understand how these choices are framed and constrained, and how women might be better supported. Implications for Practice and/or Policy In light of these findings, the ongoing promotion of adoption by the American anti-abortion movement is unlikely to impact women’s abortion decisions, because very few women pursuing abortion are interested in adoption. Thus, political messaging presenting adoption as worthy common ground in the abortion debate (The White House, 2012), or proposed laws mandating classes about adoption for women pursuing abortion (Bassett, 2013), fail to reflect the way women make pregnancy decisions. This framing is not merely an abstract, political one for women seeking abortion care. Publicly funded family planning facilities more commonly refer for adoption than abortion (Hebert, Fabiyi, Hasselbacher, Starr, & Gilliam, 2016), and some mandated abortion counseling scripts continue to be politicized in such a way as to promote adoption (Joffe, 2013; Johnson, 2014). This promotion of adoption, as an alternative to abortion, both in politics and practice, seems to have little grounding in how women actually consider their pregnancy options. Acknowledgments The authors thank Sarah Raifman for assistance in coding; Rana Barar and Sandy Stonesifer for study coordination and management; Mattie Boehler-Tatman, Janine Carpenter, Undine Darney, Ivette Gomez, C Emily Hendrick, Selena Phipps, Brenly Rowland, Claire Schreiber and Danielle Sinkford for conducting interviews; Michaela Ferrari, Debbie Nguyen and Elisette Weiss for project support; Jay Fraser and John Neuhaus for statistical and database assistance; and all the participating providers for their assistance with recruitment. References Aiken, A., Borrero, S., Callegari, L., & Dehlendorf, C. (2016). Rethinking the pregnancy planning paradigm: Unintended conceptions or unrepresentative concepts? Perspectives on Sexual and Reproductive Health, 48(3), 147–151. Bachrach, C., Stolley, K., & London, L. (1992). Relinquishment of premarital births: Evidence from National Survey Data. Family Planning Perspectives, 24(1), 27–32. Bassett, L. (2013). Texas bill would require women to take adoption class before abortion. Huffington Post. Available from: www.huffingtonpost.com/2013/ 07/31/texas-adoption-bill_n_3684687.html. Accessed: February 9, 2016. Biggs, A., Gould, H., & Foster, D. (2013). Understanding why women seek abortions in the US. BMC Women’s Health, 13, 29. Bird, C., & Rieker, P. (2008). Gender and health: The effects of constrained choices and social policies. New York: Cambridge University Press. Chandra, A., Abma, J., Maza, P., & Bachrach, C. (1999). Adoption, adoption seeking, and relinquishment for adoption in the United States. Advance Data, National Center for Health Statistics, (306), 1–16. Charmaz, K. (2006). Constructing grounded theory. London: Sage.

Child Welfare Information Gateway. (2011). How many children were adopted in 2007 and 2008? Washington, DC: US Department of Health and Human Services. Christian, C., McRoy, R., Grotevant, H., & Bryant, C. (1997). Grief resolution of birthmothers in confidential, time-limited mediated, ongoing mediated, and fully disclosed adoptions. Adoption Quarterly, 1(2), 35–58. Dobkin, L., Gould, H., Barar, R., Ferrari, M., Weiss, E., & Foster, D. (2014). Implementing a prospective study of women seeking abortion in the United States: Understanding and overcoming barriers to recruitment. Women’s Health Issues, 24(1). Donnelly, B., & Voydanoff, P. (1991). Factors associated with releasing for adoption among adolescent mothers. Family Relations, 40, 404–410. Early Growth and Development Study. (2006). Agency report: Birth parent summary statistics from all sites. Ellison, M. (2003). Authoritative knowledge and single women’s unintentional pregnancies, abortions, adoption, and single motherhood: Social stigma and structural violence. Medical Anthropology Quarterly, 17(3), 322–347. Finer, L., Frohwirth, L., Dauphinee, L., Susheela, S., & Moore, A. (2005). Reasons US women have abortions: Quantitative and qualitative perspectives. Perspectives on Sexual and Reproductive Health, 37(3), 110–118. Foster, D., Gould, H., Taylor, J., & Weitz, T. (2012). Attitudes and decision making among women seeking abortions at one U.S. clinic. Perspectives on Sexual and Reproductive Health, 44(2), 117–123. Foster, D., & Kimport, K. (2013). Who seeks abortions at or after 20 weeks? Perspectives on Sexual and Reproductive Health, 45(4), 210–218. Fravel, D., McRoy, R., & Grotevant, H. (2000). Birthmother perceptions of the psychologically present adopted child: Adoption openness and boundary ambiguity. Family Relations, 49(4), 425–433. Ge, X., Natsuaki, N., Martin, D., Neiderhiser, J., Villareal, G., Reid, J., . Reiss, D. (2008). Bridging the divide: Openness in adoption and postadoption psychosocial adjustment among birth and adoptive parents. Journal of Family Psychology, 22(3), 529–540. Grotevant, H., & McRoy, R. (1997). The Minnesota/Texas Adoption Research Project: Implications of openness in adoption for development and relationship. Applied Developmental Science, 1(4), 168–186. Guttmacher Institute. (2015). Laws affecting reproductive health and rights: State trends at midyear, 2015. New York: Guttmacher Institute. Hebert, L., Fabiyi, C., Hasselbacher, L., Starr, K., & Gilliam, M. (2016). Variation in pregnancy options counseling and referrals, and reported proximity to abortion services, among publicly funded family planning facilities. Perspectives on Sexual and Reproductive Health, 48(2), 65–71. Henney, S., Ayers-Lopez, S., McRoy, R., & Grotevant, H. (2007). Evolution and resolution: Birthmothers’ experience of grief and loss at different levels of adoption openness. Journal of Social and Personal Relationships, 24(6), 875– 889. Joffe, C. (2013). The politicization of abortion and the evolution of abortion counseling. American Journal of Public Health, 103(1), 57–65. Johnson, K. (2014). Protecting women, saving the fetus: Symbolic politics and mandated abortion counseling. Women’s Studies International Forum, 47, 36– 45. Jones, R., Frohwirth, L., & Moore, A. (2008). “I would want to give my child, like, everything in the world”: How issues of motherhood influence women who have abortions. Journal of Family Issues, 29(1), 79–99. Jones, R., & Jerman, J. (2013). How far did US women travel for abortion services in 2008? Journal of Women’s Health, 22(8), 706–713. Jones, R., & Jerman, J. (2014). Abortion incidence and service availability in the United States, 2011. Perspectives on Sexual and Reproductive Health, 46(1). Jones, R., & Kavanuagh, M. (2011). Changes in abortion rates between 2000 and 2008 and lifetime incidence of abortion. Obstetrics and Gynecology, 117(6), 1358–1366. Jones, R., & Kooistra, K. (2011). Abortion incidence and access to services in the United States, 2008. Perspectives on Sexual and Reproductive Health, 43(1), 41–50. Krahn, L., & Sullivan, R. (2015). Grief & loss resolution among birth mothers in open adoption. Canadian Social Work Review, 32(1-2), 27–48. March for Life Education and Defense Fund. (2014). Adoption: A noble decision. Available from: http://marchforlife.org/adoption-a-noble-decision/. Accessed: February 9, 2016. Miller, B., & Coyl, D. (2000). Adolescent pregnancy and childbearing in relation to infant adoption in the United States. Adoption Quarterly, 4, 3–25. Monte, L., & Ellis, R. (2014). Current population survey: Fertility of women in the United States: 2012. Washington, DC: U.S. Department of Commerce. Moore, N., & Davidson, J. (2002). A profile of adoption placers: Perceptions of pregnant teens during the decision-making process. Adoption Quarterly, 6(2), 29–41. Moss, D., Snyder, M., & Lin, L. (2015). Options for women with unintended pregnancy. American Academy of Family Physicians, 91(8), 27–48. Namerow, P., Kalmuss, D., & Cushman, L. (1993). The determinants of young women’s pregnancy-resolution choices. Journal of Research on Adolescence, 3, 193–215.

G. Sisson et al. / Women's Health Issues xxx-xx (2016) 1–9 Namerow, P., Kalmuss, D., & Cushman, L. (1997). The consequences of placing versus parenting among young unmarried women. Marriage and Family Review, 25, 175–197. Roberts, S., Fuentes, L., Kriz, R., Williams, V., & Upadhyay, U. (2015). Implications for women of Louisiana’s law requiring abortion providers to have hospital admitting privileges. Contraception, 91, 368–372. Roberts, S., Gould, H., Kimport, K., Weitz, T., & Foster, D. (2013). Out-of-pocket costs and insurance coverage for abortion in the United States. Women’s Health Issues, 24(2), 211–218. Rocca, C., Kimport, K., Gould, H., & Foster, D. (2013). Women’s emotions one week after receiving or being denied an abortion in the United States. Perspectives on Sexual and Reproductive Health, 45(3), 122–131. Rocca, C., Kimport, K., Roberts, S., Gould, H., Neuhaus, J., & Foster, D. (2015). Decision rightness and emotional responses to abortion in the United States: A longitudinal study. Plos One, 10, e0128832. Roe v Wade. (1973). ABC Nightly News. New York: ABC News. Sisson, G. (2015). “Choosing Life”: Birth Mothers on Abortion and Reproductive Choice. Women’s Health Issues, 25(4), 349–354. Smith, S. (2007). Safeguarding the rights and well-being of birthparents. New York: Donaldson Adoption Institute. The White House. (2012). Statement by the president on Roe v. Wade anniversary. Available from: www.whitehouse.gov/the-press-office/2012/01/22/statementpresident-roe-v-wade-anniversary. Accessed: February 9, 2016. Upadhyay, U., Weitz, T., Jones, R., Barar, R., & Foster, D. (2014). Denial of abortion because of provider gestational age limits in the United States. American Journal of Public Health, 104(9), 1687–1694.

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Author Descriptions Gretchen Sisson, PhD, is a research sociologist with Advancing New Standards in Reproductive Health (ANSIRH), Department of Obstetrics, Gynecology, and Reproductive Sciences, at the University of California, San Francisco. Her research focuses on social constructions and representations of parenthood and reproductive choice, including abortion/adoption.

Lauren Ralph, PhD, MPH, is an epidemiologist at the ANSIRH at the University of California, San Francisco. Her research analyzes on the consequences of unintended pregnancy, with a particular focus on adolescents and young adults.

Heather Gould, MPH, is a senior research analyst at ANSIRH at the University of California, San Francisco and research director of the Turnaway Study. She is interested in women’s reproductive health outcomes related to unintended pregnancy, abortion and childbirth, and experiences accessing and receiving health services.

Diana Greene Foster, PhD, is a demographer, Director of Research at ANSIRH at the University of California, San Francisco, and principal investigator of the Turnaway Study. Her work examines family planning policies and the effect of unintended pregnancy on women’s lives.