This questionnaire (below) was posted on the internet during 2004 and 2005, as a preliminary "reaching out" to natural mothers to find out what their experiences were of losing their babies to adoption. Even though it was not a scientifically-valid survey, this questionnaire will help us to identify issues for a future research study.

2006 UPDATE: We are currently compiling statistics from responses, and these will be published on this website. (Identities will be kept confidential).

Many Thanks to the Wonderful Mothers Who Responded!!

PART A: CONTACT INFORMATION (will be kept strictly confidential and not shared without your express permission)

Name: (required)
Email address: (required)
Mailing Address: (street address or box number, city, province/territory/state, postal code)
(required)
The province/state your child was born in:
The province/state your child was surrendered in:
Your age at time of pregnancy/surrender: ____ years old
Year of pregnancy/surrender:
Name of maternity facility:
Name of adoption agency (or CAS, government ministry, lawyer, hospital, etc. that oversaw the adoption):

1) During your pregnancy did you reside at a (check all that apply):

• Wage home
• Maternity facility
• with relatives
• any other place away from where you normally lived (give details):

WAGE HOMES

2) Were you in a wage home prior to entering a maternity facility?

If "NO," proceed to Question 6.

3) What duties did you perform in the wage home?

4) Were you permitted free egress in and out of the wage home?

5) Were you permitted reasonable and usual phone contact with friends/family while in the wage home?

Comments or details about wage home?

MATERNITY FACILITIES

6) Were you in a maternity facility? If "NO," proceed to Question 26.

CONTROL OF PHYSICAL ENVIRONMENT WITHIN MATERNITY FACILITY

7) Were you assigned an assumed name in the maternity facility?

8) Did the maternity facility take away your personal clothing and replace it with clothing owned by the home?

9) Did the maternity facility restrict your access to personal funds?

10) Did the maternity facility restrict your access to reasonable and usual phone contact with friends/family?

11) Did the maternity facility allow you to send/receive mail in sealed envelopes?

12) Did the maternity facility restrict your ingress and egress from the home?

13) Did the maternity facility restrict the number /type of visitor/visits you could have?

14) Did the maternity facility restrict your contact with your child's father while you were in the home?

Comments or details about physical environment of the maternity facility?

CONTROL OF EMOTIONAL ENVIRONMENT WITHIN MATERNITY FACILITY

15) Were you shamed or ridiculed by staff/caseworker while in the maternity facility?

16) Were you labeled with a psychiatric label by staff/caseworkers while in the maternity facility?

17) Did you feel an unspoken element of disgrace from staff/caseworker while in the maternity facility?

18) Did you have to attend regular meetings with caseworker/staff while in the maternity facility?

19) If yes, did the content of these meetings focus on your shortcomings as a mother?

20) Please check all that apply. While in the maternity facility, did you frequently feel:

lonely afraid upset anxious uncertain

fatigued exhausted powerless vulnerable stressed

hopeless helpless depressed defeated dependent

21) If yes, was there emotional support available from staff/caseworkers when needed?

22) Were you told that your thoughts, perceptions, and/or beliefs concerning your pregnancy, your baby's father and/or your own personal abilities were seriously incorrect while in the maternity facility?

23) Were you told that you would be an insufficient parent while in the maternity facility?

24) Were you told (check all that apply):

- that your baby would be "better off without you"?
- that "if you love the baby you will let the baby go"?
- that you "needed to do the right thing for the baby"?

25) If you checked any items in Question 24 , were you able to accept these statements as factual without an intellectual and/or emotional struggle?

Comments or details about emotional environment within the maternity facility?

LANGUAGE USED BY PROFESSIONALS/PARENTS

26) What types of professionals were in personal contact with you or counseled you regarding the adoption?

• adoption agency social worker or staff member
• government social worker
• maternity facility social worker or staff member
• nuns (order, if known: )
• clergy (church, if known: )
• adoption lawyer
• other (please describe)

27) Did any of these refer to you as an:

• "unwed mother?"
• "birthmother?"
• other (please give details: )

28) Did any of these professionals call you a derogatory name such as "whore," "slut," etc.?
If so, whom?

29) Did any of these professionals use certain words and phrases that made you feel distanced or removed from your motherhood?

30) Were you told adoption was "in the best interests of your child?"

31) Were you told your child would be "a gift to an infertile couple?" or words to that effect?

32) Were you told you were unworthy to keep and raise your baby?

Comments or details about language used by professionals/parents?

SOCIAL WORKERS

33) Did any social workers encourage you to "give up" your baby?

34) Were you assured by social workers that you would "forget this ever happened and go on with your life?"

35) Were you told by social workers that your baby "needed a mother and a father?"

36) Were you warned by social workers that no man would ever marry a single woman with a child?

37) Were you warned by social workers that other children would never play or associate with your child if you kept him or her?

38) Were you warned by social workers that no one would employ a single mother?

39) Were you warned by social workers that no one would rent to a single mother?

40) Were you warned by social workers that no one would lend credit to a single mother?

Comments or details about social workers?

THREATS OF PHYSICAL VIOLENCE OR OTHERWISE THREATENED

41) Were you ever physically threatened by anyone - including your parents or boyfriend, even a social worker - during your pregnancy or prior to formally signing the adoption documents to surrender your child?

If so, please explain the experience(s) in detail:

42) Where you ever threatened with (check all that apply):

• imprisonment?
• juvenile home detention?
• jail?
• being placed in any restrictive environment other than a maternity institution? If so, please explain:

43) Were you ever threatened in any other manner that has not been mentioned?

If so, please explain the experience(s) in detail:

Part B - Pre-Delivery: Other Comments or Details

Are there any other comments or details you would like to add about your pre-delivery experiences (e.g. wage homes, maternity facilities, professionals, social workers, etc.)?

44) Did you give birth:

• at a maternity facility
• in the hospital
• at your parents' home
• other

45) Were you medicated during labor? If yes, please list medications you received if you know them:

46) Were you coached through labor by delivery staff?

47) Did you have family support during labor?

48) Were you physically restrained in labor?

49) Were you told the sex of your baby/time of your baby's birth in the delivery room?

50) Were you given any information about your baby's physical condition at birth?

51) Did you see your baby in the delivery room?

52) Did you see your baby in the recovery area?

53) Did you see your baby in the post partum area?

54) How soon after birth were you taken back to the maternity facility?

55) Did you see/care for/nurse/feed/hold your baby any time after birth?

56) Were you given the drug DES (diethylstilbestrol), a synthetic form of estrogen - a female hormone, at any time during your pregnancy, delivery or post partum?

Part C- Labor and Delivery: Other Comments or Details

Are there any other comments or details you would like to add about your labor and delivery experiences?

PRE-SURRENDER COUNSELING

57) Were you counseled about surrender by the staff/caseworker in the maternity facility or by the adoption agency staff?

58) Were you counseled that there could be emotional consequences to you if you placed your child for adoption?

59) Were you counseled that there could be emotional consequences for the child if you placed your child for adoption?

60) Were you warned that adoption could be emotionally harmful to you and/or your child?

61) Were you counseled that adoption was best for your baby?

62) Were you counseled that adoption was best for you?

63) Were you counseled that you had no other real options in your situation but to place your baby for adoption?

64) Were you warned by staff/caseworkers of harmful consequences for you and your baby should you keep your baby?

65) Were you assured that the only people who actually had your best interest at heart were the staff/caseworkers?

66) Were you assured that the only people competent to handle your situation were staff/caseworkers?

67) Did you have adequate time to reflect on the consequences of surrender after giving birth, but before you signed the papers?

Comments or details about pre-surrender counseling?

INFORMATION ABOUT OTHER OPTIONS PRE-SURRENDER

68) Were you informed of any options other than surrender by staff/caseworker?

69) Were you informed that you could sue the father for child support by staff/caseworker?

70) If you were in the United States, were you informed of your options vis_a_vis federal welfare assistance by staff/caseworker?

71) If you were in the United States, were you informed by staff/caseworker that you could receive Aid to Families with Dependent Children?

72) Were you informed by staff/caseworker of any provincial/state welfare assistance?

Comments or details about other options given to you (or if any were)?

WHAT DID YOU BELIEVE CONCERNING YOUR OPTIONS?

73) Did you feel that there was no way out of your situation except to surrender your baby for adoption as advised by
staff/caseworker?

74) Did you believe that the staff/caseworkers were the only people you could trust at the time you signed?

75) Did you believe that the staff/caseworkers cared about you and your baby?

76) Did you believe that you were doing the right thing because the staff/caseworkers told you so?

77) If yes, do you still believe it?

78) Did staff/caseworkers ask you what you wanted to do about your baby?

Comments or details about what you believed concerning your options?

Part D - Pre-Surrender: Other Comments or Details

Are there any other comments or details you would like to add about your pre-surrender experiences?

79) Did you sign the papers in the hospital?

80) Did you feel the staff/caseworkers hurried you into signing the papers?

81) Did the staff/caseworkers insist you sign the papers "today"?

82) Was a lawyer present when you signed the papers?

83) Did you have your own legal representation when you signed the papers?

84) Was a judge present when you signed the papers?

85) Were you medicated when you signed the papers?

86) Were you threatened with physical or mental harm if you did not sign the papers?

87) Was the decision to surrender yours or someone else's?

88) Did you, or anyone you knew, make any effort to keep your (or their) baby?

89) Check all that apply. On the day you signed the papers, did you feel:

lonely afraid upset anxious uncertain

fatigued exhausted powerless vulnerable stressed

hopeless helpless depressed defeated dependent

Part E - Surrender: Other Comments or Details

Are there any other comments or details you would like to add about your surrender experiences?

90) Did you attempt to revoke your consent?

91) If yes to Question 90, how soon after signing did you attempt to revoke consent?

92) Did you receive adequate follow up after signing surrender documents?

Comments or details regarding follow-up?

93) What post surrender effects, physical and mental, do you feel you have suffered over the years? Please be as specific as possible.

94) In what ways has losing your infant affected your life? Please be as specific as possible.

95) Have you sought counseling?

96) If Yes to Question 95, was the counseling you received specific to your experience of surrendering your child to adoption?

Part F- Post-Surrender: Other Comments or Details

Are there any other comments or details you would like to add about your post-surrender experiences?

97) Did you want to keep your baby?

Is there anything else you would like to add to your response?