Deaths Associated with Unregulated Infant Abandonment Boxes Call for HHS Action:
An Open Letter to HHS Leadership about Policy Responses to Crisis Pregnancies
To: Secretary Xavier Becera, US Health and Human Services
Cc: Dr. Lori Moore-Merrell, Administrator, US Fire Administration
Dr. Robert M. Califf, Commissioner of Food and Drugs
Re: Deaths Associated with Unregulated Infant Abandonment Boxes Call for HHS Action
Dear Secretary Becerra,
Thank you for your dedicated service to children and families across the United States.
We are writing as concerned child welfare and maternal health scholars, clinicians, legislators & policymakers, educators, advocates, indigenous leaders, and concerned citizens – from across the US – to request increased HHS involvement in public health policy responses to crisis pregnancies. Specifically, we seek your oversight of a rapidly expanding network of unregulated devices under your purview.
These devices—infant abandonment boxes—are unregulated modern versions of medieval foundling wheels with substantial safety and legal risks. The first US box was installed in 2016. Installation efforts have been especially substantial over the past two years. The US has recently installed over 280 of these infant abandonment boxes in medical centers and fire stations across the country, with new boxes rolling out each week.
What is an Infant Abandonment Box?
Infant abandonment boxes are black metal receptacles built into exterior walls of fire stations and medical centers. They are equipped with alarms, video monitoring, and temperature controls, with exterior doors for a parent to surrender an infant, and interior doors for staff to retrieve the infant. Designed to expedite anonymous infant surrender, the boxes are mostly produced and marketed by a single manufacturer and they cost $20,000 each for installation fees and a 5-year rental term. Some boxes are funded by local advocates; others are funded through state grants (e.g., Indiana’s recent allocation of $1 million for additional boxes).
Map of Infant Abandonment Boxes
Rationale for Infant Abandonment Boxes
Despite birth rates dropping across most of the US, birth rates are rising in thirteen US states. Concerned that parents in crisis may increasingly abandon their infants or commit infanticide, state legislators in 25 states recently expanded their safe haven infant surrender laws to permit the use of infant abandonment boxes. Similar legislative efforts are underway in several other states.
While safe haven surrenders traditionally occur through a face-to-face encounter with a nurse or EMS worker, infant abandonment boxes require no personal interaction and thereby curtail crisis counseling and medical care. This lack of contact with medical professionals is of particular concern because individuals most at-risk for this type of infant abandonment are known by experts to be less likely to receive prenatal care and medical assistance during childbirth.
We applaud advocates’ and legislators’ efforts to reduce unsafe abandonments and infanticides and are heartened to see increased public interest in protecting our society’s most vulnerable babies. As implemented, however, infant abandonment boxes may fail to meet the needs and wishes of the target population. In the absence of improved oversight, these devices introduce several risks and dangers to infant and maternal health and are fraught with unintended harms and negative consequences of which state lawmakers may be largely unaware.
Two Associated Deaths in 2024
Over the past eight months, the use of these boxes has seen two associated deaths. On October 13, 2024, a deceased infant, with attached placenta, was placed into an infant abandonment box in Idaho. In March, a mother overdosed and died hours after having placed her infant into an infant abandonment box. These two deaths are especially notable since boxes are only beginning to be put to use, with only 53 surrenders to date.
These two deaths point to the need for earlier intervention and crisis counseling.
Harms and Unintended Consequences
The unregulated use of infant abandonment boxes poses a wide range of harms and unintended consequences to both babies and parents faced with crisis pregnancies.
- Pediatric Safety Concerns
Adoptee rights groups and the Maryland Section of the American College of Obstetricians and Gynecologists recommend a halt to infant abandonment boxes given “no research or clinical evidence of [their] safety or appropriateness.”
The main box manufacturer, Safe Haven Baby Boxes (SHBB), states, “The FDA has determined that the Safe Haven Baby Box does not qualify as a medical device and, therefore, does not require FDA approval. Because our baby boxes are not commercially for sale, they do not require CSPC regulation.” SHBB has declined to pursue Underwriters Laboratories (UL) listing.
The infant’s health is reliant upon the device’s heating and cooling elements, and their retrieval from the device is contingent upon alarms and video streams. Reliability concerns are compounded by some locations that lack 24/7 onsite staff, slowing response times. For example, first responders at some fire stations may learn of an infant’s arrival through a mobile alert while out responding to a call. The anonymity of infant abandonment boxes also precludes awareness of the child’s medical history, which complicates treatment decisions for infants who may need timely medical care.
Recognizing the need for safeguards, Maine and Ohio have disabled or stalled installation of infant abandonment boxes pending meaningful oversight. Other states including Nebraska, and Michigan have declined infant abandonment boxes due to safety concerns, but advocates continue to press for boxes in all states, as reflected in annual state bills and marketing communications. Child welfare advocates in many states have voiced opposition but have failed to stop the rollout of infant abandonment boxes. Additional state-specific information is summarized here. - Removing Child Protective Services (CPS) Oversight
Infant abandonment boxes are quietly assuming roles traditionally played by medical and child welfare professionals. At the moment of relinquishment, infant abandonment boxes stand in the role previously assumed by a trained medical professional. After the surrender, fire station staff in some jurisdictions are empowered to forgo CPS notification of received infants and transfer the infant directly to a private adoption agency of their choice. Omitting CPS limits access to services and eliminates the tracking of long-term outcomes that could otherwise improve future policy and care. - Informed Consent
At-risk families should be supported to make decisions resonant with their values, needs, and preferences, a process which requires the availability of communication about alternatives. However, widespread marketing of boxes decreases understanding of other options. Individuals may be disproportionately compelled to use infant abandonment boxes despite their risks and challenges, resulting in undue increases in family separation. Infant abandonment boxes may indeed be a worthy policy response, but they should not be perceived by Americans as their primary, or only, option.- Marketing of infant abandonment boxes, on social media and billboards, is widespread but largely fails to mention alternatives to boxes, which include temporary placement, adoption, kinship care, and family preservation funds.
- Signage on the infant abandonment boxes also fails to inform parents of alternatives and omits mention of terms required of surrendering parents to protect them from prosecution (e.g., the infant must meet state-specific age requirements and cannot show signs of harm, such as a positive toxicity screen).
- Signage also fails to disclose how infant abandonment laws rapidly terminate birth parents’ rights, which works against reunification.
- Parents have the right to understand all options available to them, yet training from the main box manufacturer (SHBB) discourages any discussion with parents about alternatives to anonymous surrender.
- Indian Child Welfare Act
Several tribes have publicly objected to the use of infant abandonment boxes since they circumvent provisions within the Indian Child Welfare Act that preserve a child’s right to tribal membership and cultural heritage. - Rights of the Child to their Identity
All infants left in infant abandonment boxes are denied the possibility of emotional and social benefits of an ongoing connection to a birth parent or an adoption within their extended family—options with demonstrated long-term benefits. They are also denied information about their family’s medical history, which can be gathered during traditional in-person surrenders. - Crime Concealment
Some scholars and legislators, including Nebraska Senator Carol Blood, have raised concerns that infant abandonment boxes “could unknowingly provide concealment [of] crimes such as rape, incest or human trafficking.” - Lessons Learned from Other Countries’ Use of Infant Abandonment Boxes
Most countries have reduced or phased out infant abandonment boxes due to the United Nations’ stance safeguarding a child’s rights to their identity – and based on fear of misuse (e.g., toddlers placed into infant abandonment boxes). Many countries prefer known approaches to reduce abandonment and infanticide, including accessible contraception and confidential hospital births (discussed below). Countries that continue to use boxes do not rely on them as their primary policy but use them in addition to the policies mentioned above. - Contract Terms from Main Manufacturer
SHBB contracts have terms that limit the roles of public service providers. SHBB contracts specify they have control over public signage on the boxes, which impedes informed consent. Contracts also specify that SHBB has first rights to hold press conferences to announce the arrival of any infant to the box instead of permitting the local jurisdiction to control public messaging. - Support Services & Crisis Hotlines
People experiencing crisis pregnancies face challenges acquiring timely and comprehensive information to guide their decision-making. The landscape could benefit from an expansion of crisis pregnancy support services through HHS’ National Maternal Mental Health Hotline. In order for at-risk communities to know about HSS’ hotline, a robust public service campaign is requisite.
Specific Requests to HHS
We call on your office for two actions.
#1 – HHS Oversight of Infant Abandonment Boxes
First, we ask that HHS act as quickly as possible to specify guidance on how these boxes are manufactured, installed, maintained, and marketed. As part of this effort, we ask the FDA to reconsider whether these boxes qualify as a medical device (and thereby require FDA approval).
#2 – HHS Endorsement of Confidential Birth Policies within Hospitals
It is widely known that the parents who are at risk of infant abandonment are in crisis, usually giving birth alone and without medical care. State legislators often perceive that these parents would otherwise unsafely abandon their child (e.g., in a dumpster) or commit infanticide. Mothers who intentionally kill their children, however, are extremely rare and in need of different kinds of interventions than parents experiencing other, more frequently occurring, types of crisis pregnancies.
Rather, the people contemplating the use of boxes as a last resort would benefit from greater awareness of alternatives, crisis counseling and medical support. Many are not averse to face-to-face encounters. Tragically, these parents often wish they could keep their child, but have no knowledge of the many alternatives and support services available to them. This information vacuum is especially true in places where infant abandonment boxes exist, as their substantial marketing efforts seem to be crowding out public communications about alternatives.
It is known that many people who initially request Safe Haven surrender keep their babies when they learn about alternatives and support services.
Recognizing that infant abandonment boxes are an incomplete policy solution to rising numbers of crisis pregnancies, we ask that HHS endorse another policy, more effective than boxes at addressing the needs of these at-risk parents and their children: confidential birth.
“Confidential birth” means offering at-risk pregnant people the option to give birth in a hospital (or birthing center) without having to disclose their name. This practice provides medical care and emotional safety for parents who would otherwise birth alone, affords a chance for crisis counseling and informed decision-making, and especially benefits pediatric patients giving birth following rape or incest.
US hospitals already have “Jane Doe” policies for survivors of domestic abuse and sexual assault—and for celebrities who desire anonymity while seeking medical care. If US hospitals can provide confidential care to our nation’s celebrities, we can certainly extend this service to pregnant people in crisis. Confidential birth has been offered in European and Asian countries for many decades, offering a model for a US implementation.
Data demonstrate that parents who initially request safe haven infant surrender and are then made aware of limited financial support services tend to keep their children. Additionally, a recent study by Gretchen Sission identified financial pressures—not shame or a lack of moral fitness—as the main predictor of 80% of all relinquishments. Sisson found that a few thousand dollars—or even funds for a car seat—would have been enough to help many families stay together. Sisson further stated that many parents who relinquish feel coerced into their decision, experience unabated grief, and prefer to keep their children.
During confidential birth, parents can learn from clinicians and social workers about the many alternatives currently available to keep families together, including kinship care, temporary placement, and funds to support family preservation. They could also learn about the benefits and disadvantages of open and closed adoption and Safe Haven surrender, the latter of which rapidly terminates parental authority with little chance of regaining parental rights in the future.
We are supportive of all stakeholders’ interests in reducing unsafe abandonment and infanticide, and with proper oversight, boxes could contribute to a broader policy response while upholding informed consent, health and safety of pregnant people and their infants, tribal rights, and family preservation. But, as presently used, these devices may well be doing more harm than good.
Our voices add to the growing list of interested parties expressing concern about these boxes. We urge you to please place oversight over these boxes and help hospitals offer confidential birth services. We are available to meet with your office anytime to discuss these issues.
Sincerely,
Main Signatories:
Lori Bruce, Doctorate in Bioethics, HEC-C, Yale University;
Clara Lewis, PhD, Dartmouth College;
Mark Mercurio, MD, MA, Yale University School of Medicine
Additional Signatories (updated periodically):Nebraska State Senator Carol Blood
Commissioner Diana Finegan, Citrus County Florida (continued next pages…)
Lisa Campo-Engelstein, Institute for Bioethics and Health Humanities, The University of Texas Medical Branch
Michelle Oberman, Katharine & George Alexander Prof. of Law, Santa Clara University
Elizabeth Lanphier, PhD, HEC-C, University of Cincinnati
Suzie Ciruzzi JD, MSc, PhDClinical Ethicist / St Jude Children’s Research Hospital, Memphis, Tennessee
Kelly Michelson MD MPH, Northwestern University, Lurie Children’s Hospital
Jessica Fry, MD, Lurie Children’s Hospital of Chicago
Kerry Madden-Lunsford, University of Alabama at Birmingham
Arthur Caplan, Head Division of Medical Ethics, NYU Grossman School of Medicine, NY, NY
E. A. Jurenovich, MS, LCPAA, LPC, LMFT Founder & Executive Director of Abrazo Adoption Associates
Dawn Geras, Executive Chairperson, Save Abandoned Babies Foundation
Fatima Abu Bakr, EMT, Hartford Healthcare
Nanette Elster, JD, MPH, Professor of Bioethics, Neiswanger Institute for Bioethics, Loyola University Chicago Stritch School of Medicine
Jennifer Archer Papa, RN BSN RNC CPLC Coordinator Neonatal Bereavement Team YNHH
Gregory Luce, Attorney and Founder, Adoptee Rights Law Center
Faith Fletcher, Baylor College of Medicine Center for Medical Ethics and Health Policy
Josh Elliott, Connecticut General Assembly
Erin Paquette, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine
Joanne Suarez, MBE, Prospera Institute
Evie Marcolini Emergency Physician, Dartmouth-Hitchcock Medical Center
Marley Greiner, Executive Chair, Bastard Nation: the Adoptee Rights Organization. Publisher, Stop Safe Haven Baby Boxes Now
Brooke Laufer Clinical Psychologist
Noelle Ozimek, Harvard Medical School
Dr. Deborah Loeff University of Chicago Medicine
Jennifer Cho, Senior Lecturer at University of Maryland, College Park
Amy Hohmann
Lou Hart, MD / Yale School of Medicine, Pediatrics
Nebraska State Senator Megan Hunt
Lore Mariano
Sharon Ostfeld-Johns, Yale University School of Medicine
Gretchen Sisson, PhD, Advancing New Standards in Reproductive Health, University of California, San Francisco
Stephen Latham, Interdisciplinary Center for Bioethics, Yale University
Sarah N. Cross, MD, Yale School of Medicine
Maureen Flatley, expert in child welfare & adoption policy
Alla Vash-Margita, Yale University
Susan Gilbert, The Hastings Center
Ashley S. Weitz, victim advocate
Dr. Patrice Martin, Adoptee Rights Activist – Foundling
Micah Orliss, Ph.D., University of Southern California
Stephanie Toti, Executive Director, Lawyering Project
Gerard Vong, D.Phil., Associate Professor, Emory University
Uchenna Anani, MD
Madeleine Hutchins, Yale Community Bioethics Forum
Seema K. Shah, JD, Northwestern University
Michelle McGowan, Mayo Clinic
Katherine Kohari, MD Yale School of Medicine
Emily M. Douglas, Ph.D., Montclair State University
Laura Bothwell, PhD, Yale School of Public Health
Sophie L. Schott, MS1, McGovern Medical School, Texas
Velina Chavarro, MD Resident Lahey Hospital and Medical Center
Ari Silver-Isenstadt
Helen Winston, Public Defender in Nebraska
Eric Miller
Martin A. Strosberg, Ph.D, . Emeritus Professor, Union College
Diana Barnes private clinical practice
Elizabeth Berman
Iris Thompson, Yale Community Bioethics Forum
Paul Cummins, Ph.D. Clarkson University
Stephen Keogh, Attorney
Ellen Dupuy d’Angeac
Nia Johnson, Duke University
Alyssa Burgart, MD, MA, Stanford University School of Medicine
Jeanne Heifetz
Sundes Kazmir, MD, Assistant Professor of Pediatrics, Yale School of Medicine
Alice Baker
Alec Rutherford, Yale University School of Medicine
Julian Willard
Lyubina Yankova, Yale New Haven Children’s Hospital
Nirali Butala, MD
Adrienne Sandiford, Legal Assistant
Terri Seligman, Attorney
Annette Charles, Aim & Arrow Group
Deborah Donenfeld
Luciana McClure Southern Connecticut State University
Sarah C. Hull, MD, MBE Yale School of Medicine
Sophie Hagen
Melissa Lang, DrPH
Julius Landwirth University of New Haven
MJ Wunsche
Letitia Upton MD
DeLeith Duke Gossett, Professor, Texas Tech University School of Law
Shannon O’Malley MD
Sara Epstein
Paul David, MD
Emma McDonald Kennedy, Villanova University
Danielle M. Pacia, The Hastings Center
Anna Hadfield, Yale New Haven Hospital
Elaine Morgan MD
Charity Fox, PhD Dickinson College
Additional Concerned Parties
This is a partial list of concerned medical associations, groups, and individuals who have recently raised concerns about ethics and safety risks of infant abandonment boxes.
Adoptee Rights Law Center
American College of Obstetricians and Gynecologists (Maryland chapter)
United Nations Committee on the Rights of the Child
Rick Snyder, Governor of Michigan
Adoption Search Resource Connection
New York Adoptee Rights Coalition
Texas Adoptee Rights Coalition
Florida Senator Lauren Book
Nebraska Senator Carol Blood
Nebraska Senator Justin Wayne, head of Nebraska Legislature’s Judiciary Committee
Kansas Rep. John Carmichael
Maine Rep. Matt Moonen
Diana Finegan, Citrus County, FL Commissioner
former Indiana Senator Jean Breaux
Florida Adoption Council (affiliate of Am. Acad. Adoption & Assisted Reproduction Attorneys)
Nicole M. Homer, Ho-Chunk Nation, Legislative Attorney
Bastard Nation, Adoptee Rights Organization
Joel Gordon, A Safe Haven for Newborns spokesperson and deputy chief in Fort Lauderdale fire department
Missouri Ward Alderwoman Anne Schweitszer
Omaha Senator Justin Wayne
Jack Lessenberry, Michigan Radio’s Senior Political Analyst
Stop Baby Boxes (an adoptee-centered, non-partisan advocacy group)
Equal Access Oklahoma
Colorado Organization for Latina Opportunity and Reproductive Rights
Adoption Search Resource Connection
Coalition for Truth and Transparency in Adoption
Rev. Ronald Nydam PhD, counselor to adult adoptees in Colorado
David B. Bohl, MA, Clinical Substance Abuse Counselor (CSAC) in Colorado