Department  of  Health  and  Human  Services 
OFFICE  OF 

INSPECTOR  GENERAL 

IN-HOSPITAL  VOLUNTARY  PATERNITY 

ACKNOWLEDGMENT  PROGRAM 

Hospital  Experiences  in Sample  States 
JUNE  GIBBS  BROWN 
Inspector  General 
AUGUST  1997 
OEI-06-95-00161  OFFICE  OF INSPECTOR  GENERAL 
The mission  of the Office of Inspector  General (OIG), as mandated  by Public Law 95-452,  as 
amended,  is to protect  the integrity  of the Department  of Health and Human Services  (HHS) 
programs  as well as the health and welfare  of beneficiaries  served by those programs.  This statutory 
mission  is carried  out through  a nationwide  network  of audits,  investigations,  and inspections 
conducted  by three OIG operating  components:  the Office of Audit Services,  the Office of 
Investigations,  and the Office of Evaluation  and Inspections.  The OIG also informs  the Secretary of 
HHS of program  and management  problems  and recommends  courses  to correct  them. 
OFFICE  OF EVALUATION  AND INSPECTIONS 
The OIGs Office of Evaluation  and Inspections  (OEI) conducts  short-term  management  and program 
evaluations  (called inspections)  that focus on issues of concern  to the Department,  the Congress,  and 
the public.  The findings  and recommendations  contained  in these inspection  reports  generate  rapid, 
accurate,  and up-to-date  information  on the efficiency,  vulnerability,  and effectiveness  of departmental 
programs. 
OEIs Dallas Regional  Office prepared  this report under  the direction  of Chester  B. Slaughter, 
Regional  Inspector  General. 
Project  Staff included: 
DALLAS REGION  HEADQUARTERS 
Ruth Ann Dorrill,  Project  Leader 
 Ann OConnor,  Program  Specialist 

Michelle  Adams,  Ph.D 
 Linda Moscoe 

Karen Erickson,  Intern 
 Barbara Tedesco 

Lisa Lesh,  Intern 

Marnette  Robertson 

Sarah Taylor 

Nancy Watts 

For additional  copies of this report,  please contact the Dallas Regional  Office at (800) 8488960.  Department  of  Health  and  Human  Services 
OFFICE  OF 

INSPECTOR  GENERAL 

IN-HOSPITAL  VOLUNTARY  PATERNITY 

ACKNOWLEDGMENT  PROGRAM 

Hospital  Experiences  in Sample  States 
JUNE  GIBBS  BROWN 
Inspector  General 
AUGUST  1997 
OEI-06-95-00161  EXECUTIVE  SUMMARY 
PURPOSE 
This report  describes  birthing  hospital  capability  and progress  in administering  voluntary 
paternity  acknowledgment  programs  in 15 sample States. 
BACKGROUND 
Federal  law requires  that States implement  hospital-based  programs  for the voluntary 
acknowledgment  of paternity,  seeking to facilitate  at-birth  paternity  establishment  for children 
born to unmarried  parents.  Many  States have long administered  hospital-based  programs, 
and even now the voluntary  acknowledgment  process  may be administered  largely  at State 
discretion,  but the intent  of the Federal  mandates  is to make paternity  acknowledgment  part 
of the birth  registration  process.  This places a great responsibility  on birthing  hospital  staff 
to assist unmarried  parents  in voluntarily  acknowledging  paternity.  Our facility-level  study 
describes  the experiences  of birthing  hospitals  in implementing  voluntary  acknowledgment 
programs  and the actions  of State agencies  to assist these hospitals.  Comprehensive  mail 
surveys  were completed  by child  support  and vital  records  agencies  in 15 sample States,  and 
by 429 birthing  hospitals  within  those States.  Our sample of States includes  a broad 
spectrum  of implementation  experiences,  but generally  focuses  on States which  are farther 
along  in implementation  than the average  of their  national  counterparts. 
FINDINGS 
Birthing  hospitals  in sample States are offering  acknowledgment  services,  and State child 
support and vital  records  agencies  believe  hospitals  are capable  and willing  to administer 
paternity  programs.  Also,  both agencies  report  largely  effective  interaction  with each other 
and progress  toward  smoother  documentation  procedures.  However,  in-hospital  voluntary 
paternity  acknowledgment  programs  could be improved  by further  State agency  effort, 
including  enhanced  collaboration  with hospitals,  Statewide  implementation  of hospital 
assessments,  and use of more  interactive  training  and outreach  methods. 
OverallProgram Rating 
Nearly  all birthing  hospitals  offer  voluntary  paternity  acknowledgment  services,  and hospital 
staff are generally  positive,  viewing  the programs  as helpful  to parents. 
Over half of hospitals  report  the program  is both  simple to administer  and easy for parents  to 
understand,  and most child  support and vital  records  agencies  rate hospital  staff as good in 
their  ability  and effort  to administer  the programs. 
i  Monitoring of HospitalParticipation 
Although  hospitals  report  widespread  program  participation,  only  --of the  15 sample child 
support agencies monitor  hospital  participation. 
Most hospital  monitoring  includes  only  the collection  of data,  and not the evaluation  of 
process,  and few child  support agencies  offer  feedback  to hospital  staff. 
RelationshipsBetween Key Players 
Most hospitals  report  effective  relationships  with vital  records,  and are fairly  positive  about 
child  support agencies  but often have trouble  identifying  them. 
Child  support agencies  which pay hospitals  for completed  paternity  acknowledgments  report 
this enhances  hospital  relationships,  but hospital  respondents  appear  largely  unaffected  by 
payment. 
Child Support and VitalRecords Agency Assistance to HospitalStaff and Parents 
Not all hospitals  are provided  with staff training  materials  to assist them in the 
acknowledgment  process,  and most hospitals  rely primarily  on brochures. 
Child  support agencies  are not proactive  in determining  hospitals  continuing  training  needs, 
with nearly  half  relying  on hospitals  to request more materials. 
Some child  support  agencies  and hospitals  conduct  follow-up  after discharge  with parents 
who do not acknowledge  paternity  during  their  hospital  stay. 
Nearly  all child  support agencies  in sample States report  educational  outreach  efforts  to 
parents,  but for fewer hospitals  report  such materials  are available  and utilized,  and only  a 
quarter  of hospitals  conduct  prenatal  outreach. 
AdditionalProgram Constraints 
The quality  of hospital  services  is limited  somewhat  by internal  hospital  factors  such as 
insufficient  staffing  levels  and over-reliance  on birth  certificate  worksheets. 
Half of child  support  agencies  and a quarter  of hospitals  requiring  notarization  of paternity 
documents  report  it negatively  impacts acknowledgment. 
There  is a lack of clarity  about the role of hospital  staff in communicating  with parents, 
particularly  as it concerns  their  serving  as advocates  of paternity  acknowledgment. 
Factors  external  to hospitals,  such as poor parent  relationships,  may also limit 
acknowledgments,  although  many  fathers  visit during  the mothers  stay. 
ii  RECOMMENDATIONS 
Overall,  we find hospitals  are supportive  of the paternity  acknowledgment  effort,  appear to 
recognize  its importance,  and are increasingly  capable  of successfully  conducting 
acknowledgment  procedures.  However,  State agencies,  particularly  child  support,  could do 
more to assist hospitals  in their  administration  of the voluntary  acknowledgment  process. 
Based on our findings,  we recommend  the Office  of Child  Support  Enforcement  (OCSE) take 
the following  actions to improve  the State operation  of in-hospital  paternity  acknowledgment 
programs.  The first and second recommendations  duplicate  those found in a companion 
report  on nationwide  program  implementation: 
AGENCY  INTERACTION ANLl DIWSION  OF DUTIES.  Promote interagency 
collaboration,  and assure child support and vital records agencies more clearly  define 
their respective  agency roles.  OCSE should provide  technical  assistance  to enhance  agency 
interaction  and encourage  joint  problem-solving  among child  support and vital  records 
agencies,  and should consider  encouraging  States to draft  a flexible  interagency  agreement 
which  would make clear  the procedures  and activities  specific  to each agency. 
STATEWDE  HOSPITAL ZMPLEMENTATZONAND ASSESSMENT.  Monitor  Statewide 
hospital implementation  by assuring all States collect  acknowledgment  data for each 
birthing hospital and by encouraging  development  of hospital assessment procedures. 
OCSE should provide  technical  assistance  to States in creating  hospital  assessment 
procedures,  and should consider  developing  a uniform  reporting  mechanism  for States to 
monitor  birth  and acknowledgment  data per hospital  and to report  hospital  assessment 
procedures  and outcomes. 
DEFINITZON OF HOSPITAL ROLE.  Clarify the appropriate  role of birthing hospital 
staff in providing acknowledgment  assistance to unmarried  parents.  OCSE should help 
States develop  policy  outlining  the appropriate  content  and tone of hospital  contact  with 
unmarried  parents,  particularly  in regard to their  advocating  voluntary  acknowledgment. 
AGENCY  ASSISTANCE  TO HOSPITALS.  Encourage  State agencies to more actively 
support hospital staff in implementing  acknowledgment  programs.  OCSE should provide 
technical  assistance  to help child  support and vital  records  agencies  better  serve hospitals, 
emphasizing  the distribution  and use of education  and outreach  materials  as well as 
techniques  for providing  feedback  to hospital  staff. 
. . . 
111  AGENCY COMMENTS 
We have worked  in close partnership  with OCSE throughout  the conduct  of this inspection. 
Although  we did not receive  formal  comments  from ACF on our draft  reports,  they 
demonstrated  through  their collaboration  a general  agreement  with this report  and the 
companion  reports.  We worked  with OCSE in developing  a research  methodology,  provided 
extensive  briefings  on study findings  and created  additional  documents  to meet agency  needs. 
We appreciate  their cooperation  and guidance,  and will continue  to work with them on the 
issues raised  in these reports.  The Office of the Assistant  Secretary  for Planning  and 
Evaluation  provided  its general  concurrence  with both this report  and the state 
implementation  report. 
iv  TABLE  OF  CONTENTS 
PAGE 

EXECUTIVESUMMARY  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  i 

INTRODUCTION  ..........................................  1 

FINDINGS 

 Overall  Program  Rating  .....................................  4 

 Monitoring  of Hospital  Participation  .............................  6 

 Relationships  Between Key Players  ..............................  7 

 Assistance  to Hospital  Staff and Parents  ...........................  9 

 Additional  Program  Constraints  ...............................  13 

RECOMMENDATIONS  .....................................  19 

ENDNOTES  .............................................  21 

APPENDICES 

A:  Comparison  of Sample and Non-Sample  States  .....................  A-l 

B:  Comparison  of Hospital  Data by Urbanization  and Medicaid  Discharge  Rates  ...  B-l 

C:  Confidence  Intervals  ......................................  C-1 
 INTRODUCTION 
PURPOSE 

This report  describes  birthing  hospital  capability  and progress  in administering  voluntary 

paternity  acknowledgment  programs  in 15 sample States. 

BACKGROUND 

The Omnibus  Budget Reconciliation  Act of  1993 (OBRA) amends Title IV-D of the Social 

Security  Act,  requiring  States to implement  hospital-based  programs  for the voluntary 

acknowledgment  of paternity.  The objective  of these programs  is to facilitate  at-birth 

paternity  establishment  for children  born to unmarried  parents.  Without  an establishment  of 

paternity,  unmarried  mothers  may never  obtain  a child  support order  and gain access to the 

enforcement  services  of their  State child  support office.  Establishment  of paternity  at birth 

has many  administrative,  financial  and emotional  benefits.  Mothers  often  lack information 

about the importance  of and methods  for establishing  paternity.  Consequently,  they may not 

seek to establish  paternity  until  a point at which the process becomes  more difficult. 

Paternity  researchers  agree that the most opportune  time for paternity  establishment  is the 

happy  hour  in the hospital  immediately  following  birth  and before  the release  of the 

mother  and child.  Once a child  support order  is issued,  never-married  women  are as likely 

to receive  payment  as are divorced  women. 

Many States administered  hospital-based  programs  before  this legislation,  and even now the 

voluntary  paternity  acknowledgment  process  may be structured  and administered  largely  at 

State discretion.  The voluntary  paternity  acknowledgment  process  seeks to reduce 

administrative  burdens  and provide  a healthier,  more positive  introduction  to parenting 

responsibilities.  In most States, the use of the voluntary  acknowledgment  process  in birthing 

hospitals  is the centerpiece  of this effort.  Under  the OBRA mandate,  State child  support 

agencies  must:  1) implement  hospital-based  voluntary  paternity  acknowledgment  programs  in 

every  public  and private  birthing  hospital;  2) require  that a witness or notary  public 

participate  in the signing  of voluntary  acknowledgments;  3) make available  voluntary 

acknowledgment  outreach  materials,  including  information  on parental  rights  and 

responsibilities,  and materials  for training  hospital  staff; 4) and monitor  birthing  hospital 

compliance  on an annual basis.  At their discretion,  OBRA allows  States to provide  Federal 

Financial  Participation  payments,  not to exceed 20 dollars  for each voluntary  paternity 

acknowledgment,  to birthing  hospitals. 

The Personal  Responsibility  and Work  Opportunity  Reconciliation  Act of  1996 (PRWORA) 

further  defines  paternity  establishment  and encourages  State uniformity  and accountability. 

PRWORA  requires  the following  refinements  to the procedures  listed above:  1) provision  to 

mothers  and fathers  of both written  materials  and an oral explanation  regarding  the rights and 

responsibilities  of paternity  establishment;  2) a uniform  60-day window  for rescission 

following  a voluntary  paternity  acknowledgment,  after which  acknowledgment  would 

establish  a legal finding  of paternity;  and 3) the inclusion  of State vital records  agencies  in 

1  processing  paternity  acknowledgments  and child  support orders.  Neither  law precludes  the 
use of the birth  certificate,  rather  than a separate  voluntary  paternity  acknowledgment  form, 
in acknowledging  paternity  if the birth  certificate  includes  the necessary  data elements. 
As interpreted  by the Office of Child  Support  Enforcement  (OCSE),  the intent  of both laws 
is to make voluntary  paternity  acknowledgment  part of the birth  registration  process.  This 
places a great responsibility  on birthing  hospital  staff to assist unmarried  parents  in 
voluntarily  acknowledging  paternity.  Although  child  support  and vital  records  agencies  may 
attempt to educate parents  prior  to or following  hospital  admission,  the hospital  provides  the 
crucial  arena  for at-birth  paternity  acknowledgment. 
METHODOLOGY 
After  extensive  preinspection  research,  we surveyed  both  State agencies  and birthing 
hospitals  in each of  15 sample States.  Our study objective  was to describe  birthing  hospital 
capability  and implementation,  and the actions  of child  support  and vital  records  agencies  to 
assist hospitals  in administering  acknowledgments.  This  facility-level  report  describes  the 
experiences  of birthing  hospitals  in implementing  voluntary  acknowledgment  programs  and 
the action  of State agencies  to assist these hospitals.  By using  a sample of States,  we set the 
stage for clearer  analysis  of the impact of State policy  on hospital  practices.  Comprehensive, 
pre-tested  mail  surveys  were sent to child  support and vital  records  agencies  and a sample of 
birthing  hospitals  in each sample State.  We sampled States which  ranked  highest  when 
combining  indices  of nonmarital  births  and number  of hospitals  with high-Medicaid  discharge 
rates.  We chose these measures  to ensure  adequate representation  of those facilities  more 
likely  to assist unmarried  parents  and to have need for paternity  acknowledgment  services. 
The resulting  list of States was modified  somewhat  for inclusion  of some States which 
possessed  and some States which did not possess the following  characteristics:  operation  of a 
program  prior  to the Federal  mandate,  notarization  requirement  for paternity  documents,  and 
State practice  of paying  hospitals  for completed  acknowledgments. 
Within  each State, we constructed  two strata of birthing  hospitals  and randomly  sampled 
from each.  The first stratum represents  hospitals  with a high  number  of Medicaid 
discharges,  and the second  stratum consists  of all other birthing  hospitals  in the State.2 
Few significant  differences  were found to exist between  the two strata,  but comparisons  of 
hospitals  by Medicaid  discharge  rates and urbanization  status are included  in Appendix  B. 
Our sample of States includes  a broad  spectrum  of implementation  strategies  and experiences, 
but generally  focuses  on States which  are farther  along  in implementation  than the average  of 
their  national  counterparts.  One sample State, however,  was just  beginning  program 
implementation  at the time of our data collection.  A comparison  of sample and non-sample 
States is found in Appendix  A, and confidence  intervals  for key  survey  questions  are found 
in Appendix  C.  The  15 sample States account  for 68 percent  of all U.S.  nonmarital  births 
and 59 percent  of all U.S.  birthing  hospitals.3 
In addition  to completing  the survey,  we asked the hospitals  and State agencies  to send 
examples  of paternity  acknowledgment  outreach  materials  and photocopies  of their birth 
certificates  and voluntary  acknowledgment  forms.  For child  support agencies,  the survey  instrument  focused  on the procedures  in place  for facilitating  hospital-based  paternity 

acknowledgment  programs,  their contact  with and methods  of evaluating  birthing  hospitals, 

and their procedures  for acquiring  completed  voluntary  acknowledgment  forms.  For vital 

records  agencies,  our focus was on the path of documentation  of the voluntary 

acknowledgment  data,  but also covers  interaction  with child  support offices,  outreach  to 

birthing  hospitals  and applicable  State laws governing  the use of birth  registry  information. 

In nearly  all cases,  the chief  vital records  registrar  completed  the survey.  Child  support 

enforcement  agency  surveys  were sent to each States child  support office,  where respondents 

were typically  child  support directors  or paternity  program  coordinators.  In some cases, 

small groups of agency  officers  completed  the form together.  We received  completed 

surveys  and documents  from each of the  15 State child  support and vital  records  agencies.4 

The hospital  survey  instrument  focused on hospitals  implementation  of paternity 

acknowledgment  programs  and their relationships  with State child  support and vital records 

offices.  Surveys  were directed  to birth  registration  clerks  in each facility.  In cases where 

the birth  clerks  were not responsible  for the completion  of paternity  acknowledgments,  the 

surveys  typically  were rerouted  to the appropriate  staff in obstetrics  or womens  health 

departments.  Telephone  follow-up  was conducted  with some one hundred  hospitals  who had 

not responded  one month  after the surveys  due date.  In most cases,  non-responses  were due 

to surveys  not being  routed properly.  By sending  second copies of the survey  directly  to 

those responsible  for completion  of paternity  acknowledgments,  and aggressive  telephone 

follow-up,  we were able to achieve  a response  rate of 78 percent  (429 hospitals).5 

Two companion  reports  will be issued as part of this study.  The first entitled,  In-Hospital 

Voluntary  Paternity  Acknowledgment  Programs:  State Agency  and Birthing  Hospital 

Implementation  (OEI-06-95-00160)  describes  program  implementation  nationwide  using 

survey  responses  from child  support and vital  records  agencies  in all States and the District 

of Columbia,  and the second entitled,  In-Hospital  Voluntary  Paternity  Acknowledgment 

Programs:  Best Practices  in Education  and Outreach  (OEI-06-95-00162)  highlights 

innovative  approaches  for educating  unmarried  parents  and hospital  staff.  In addition,  two 

documents  were produced  for OCSE during  our inspection  entitled  Sample State 

Summaries  and  Common  Data Elements  - State Paternity  Acknowledgment  Forms  to meet 

immediate  needs pertaining  to PRWORA  implementation. 

This study was conducted  in accordance  with the Quality  Standards  for Inspections  issued by 

the Presidents  Council  on Integrity  and Efficiency. 

3 
 FINDINGS 

While  most birthing  hospitals  in sample States report  offering  voluntary  paternity 
acknowledgment  services,  and State agencies  believe  hospitals  capable  of administering  these 
services,  unmarried  parents  could be better  served by enhanced  collaboration  between  State 
agencies  and hospitals.  Hospital  staff training  and educational  outreach  to unmarried  parents 
are often insufficient,  and many  hospitals  dont know  where  to turn for further  assistance. 
Although  hospital  staff are positive  about the worth  of voluntary  acknowledgment  efforts, 
they are confused  about their  role  in communicating  acknowledgment  information  to parents. 
In-hospital  voluntary  paternity  acknowledgment  programs  could be improved  by further  State 
child  support and vital  records  agency  effort,  including  Statewide  implementation  of hospital 
assessment  procedures  and use of more  interactive  training  and outreach  methods. 
OVERALL  PROGRAM  RATING 
Birthing HospitalsOffer VoluntaryPaternityAcknowledgment Services, and HospitalStaff 
are Generally Positive, Viewing the Programs as Helpful to Parents. 
Nearly  all birthing  hospitals  surveyed  report  offering  some form  of voluntary  paternity 
acknowledgment  service  (even  in the State just  beginning  formal  program  implementation), 
and most hospital  staff appear  to value the purpose  of paternity  acknowledgment.  Primary 
responsibility  for implementing  the in-hospital  programs  typically  lies with birth  registrars  in 
the medical  records  department  (57 percent)  or birth  registrars  in the obstetrics  department 
(20 percent),  with another  42 percent  of hospitals  relying  on other  obstetrics  staff to 
administer  the program.  Hospital  social workers  play  a significant  role  in seven percent  of 
hospitals.6  Only a single hospital  reports  a social worker  provided  by child  support held the 
primary  responsibility. 
Child  support agencies  report  hospital  staff resistance  is rare.  Thirteen  of the  15 sample 
agencies  report  only  a few or no hospitals  express  reluctance  to participate  in voluntary 
acknowledgment  programs,  and four report  no reluctance  at all among hospital  staff in their 
State.  Our survey  of hospital  staff confirms  this cooperative  attitude.  One birth  registrar 
comments,  Itis very satisfying to fill a need for parents,  and the process  only adds a step 
or two to my job.  
Seventy  percent  of hospital  respondents  agree,  rating  the in-hospital  paternity  initiatives  as 
helpful  or very  helpful  to parents.  Only three percent  deem the programs  not helpful  to 
parents,  with the remaining  27 percent  rating  the program  as somewhat  or a little helpful. 
An obstetrics  nurse at a large urban  hospital  wrote,  We have a heavy single mom Medicaid 
population,  and many here feel fathers  should be held accountable.  While most feel 
marriage  is preferable,  this process  does give an avenue  to assume some responsibility/rights 
and privileges.    Only a few hospital  respondents  say the hospital  stay is too hectic  to expect 
parents  to comprehend  the process,  or that they felt uncomfortable  dealing  with the issue. 
4 
 Over Half of HospitalRespondents Report the Programs Both Simple to Administer and 
Easy for  Parents to Understand, and Most Child Support and VitalRecords Agencies Rate 
HospitalStaff as Showing a Good Abilityand Effort in Administering the Programs. 
Half of hospital  respondents  rate the paternity  acknowledgment  process  as simple or very 
simple to administer.  Another  39 percent  say it is neither  simple  nor difficult,  and only  11 
percent  of hospitals  say the process  is difficult  or very difficult.  Even more  (58 percent)  of 
hospital  respondents  find the voluntary  paternity  acknowledgment  process  to be easy or very 
easy for parents  to understand,  31 percent  find it neither  easy nor hard,  and only  11 percent 
believe  it to be difficult  or very difficult  for parents  to comprehend.  A number  of issues 
appear to affect  whether  a hospital  rated the process  as simple  or difficult.  For example, 
hospital  staff receiving  training  and educational  materials  by their  child  support agency  or 
some other  source are more  likely  to rate the process  as simple  or very  simple to administer 
compared  with those not receiving  training  (61 vs. 48 percent).  Hospitals  reporting  an 
effective  relationship  with the vital  records  agency  also are more  likely  to rate the program 
as simple or very  simple to administer  (61 vs.  36 percent)  compared  with those with 
ineffective  relationships.  Hospitals  finding  the program  simple or very  simple to administer 
also perceive  it more helpful  to parents  (84 vs. 3 percent)  and easier  to understand  (72 vs. 7 
percent).  High-Medicaid  urban  hospitals  are more likely  than other  types to rate their 
programs  difficult  to administer  (19 vs. 9 percent),8 as are hospitals  which use a paternity 
affidavit  form  rather  than the birth  certificate  for documentation  of acknowledgment  (26 vs. 8 
percent). 
Most State agencies  rate both the ability  and effort  of hospital  staff in administering 
acknowledgments  as good,  with child  support agencies  rating  ability  slightly  higher  than 
effort.  Still,  one-fourth  of both child  support and vital records  agencies  rate effort  as fair or 
poor,  representing  a perceived  need for improvement  in a number  of States.  Interestingly, 
both State agencies  respond  quite similarly  to this evaluation  of hospital  staff.  Three  vital 
records  and two child  support agencies  in our sample States chose  not to rate hospital  staff. 
Both wrote that the quality  of staff activities  varies  too much from  hospital  to hospital  for 
them to provide  an aggregate  response.  Agency  ratings  by the remaining  States are shown in 
Table  1. 
Table 1:  ABILITY AND EFFORT OF HOSPITAL  STAFF 
Ability  Effort 

Child Support  Vital Records  Child Support  Vital Records 

Excellent 
 8%  8%  8%  8% 
(1)  (1)  (1)  (1) 
Good 
 77%  67%  67%  67% 
(10)  (8)  (8)  (8) 
Fair 
 15%  17%  17%  25% 
(2)  (2)  (2)  (3) 
Poor or Very Poor 
 0%  8%  8%  0% 
(0)  (1)  (1)  (0) 
5  MONITORING  OF HOSPITAL  PARTICIPATION 
Although Child Support and VitalRecords Agencies as Well as Birthing HospitalsReport 
WidespreadProgram Participation,Only 73 Percent of Sample Child Support Agencies 
Monitor HospitalParticipation. 
Child  support agencies  in 11 of the  15 sample  States (73 percent)  report  their  hospitals  were 
already  offering  minimal  voluntary  acknowledgment  services  prior  to OBRA, and that they 
now have Statewide hospital  participation.  Of the remaining  four  sample States which do not 
report  Statewide  implementation,  two have contacted  all birthing  hospitals  to inform  them of 
the acknowledgment  program,  one has not yet contacted  all hospitals  because  it chose to first 
target those with a higher  incidence  of nonmarital  births,  and the other was just  beginning  to 
contact  hospitals  when surveyed.  But even though  implementation  appears to be widespread, 
hospitals  reporting  use of acknowledgment  procedures  may not offer  the same type and 
degree  of service  to parents.  Some may only  complete  a paternity  affidavit  if requested by a 
parent,  while others  have very deliberate  program  implementation  strategies  which  include 
training  of hospital  staff and outreach  to unmarried  parents.  Child  support agencies  have 
been slow to adopt monitoring  and assessment  procedures  which  would allow them to 
evaluate  hospital  participation.  Child  support agencies  in 11 of the sample States (73 
percent)  report  they at least collect  minimal  data needed to monitor  individual  hospital 
participation. 9 
Most HospitalMonitoring Includes Onlythe Collectionof Data, and Not the Evaluationof 
Process, and Few Child Support Agencies Offer Feedback to HospitalStaff. 
Nearly  all of the  11 States which do monitor  hospitals  only track  the number  of 
acknowledgments  and nonmaritai  births  from each hospital,  which  is the minimum  required 
by the Federal  mandate.  Few yet attempt to evaluate  other aspects of the hospital  programs 
such as staff involvement  or parent use of outreach  materials,  and most dont provide  any 
feedback  to the hospitals  they  have assessed.  Of the four remaining  sample States which 
dont yet assess hospital  participation,  three  track the number  of acknowledgments  from each 
birthing  hospital  in their  State but do not yet monitor  hospital  participation  by comparing  that 
information  with the number  of nonmarital  births  assisted. 
Within  the  11 States which  monitor  hospital  participation,  only  20 percent  of hospitals  report 
they were monitored  or assessed in any way.  Of those which do recognize  being monitored, 
only  half  (54 percent)  attribute  the involvement  to their child  support agency.  The other 
groups hospitals  report  most likely  to monitor  their programs  or conduct  hospital  assessments 
are the vital records  agency  (28 percent),  and their  own hospital  administration  (7 percent). 
Therefore,  only  a small number  of birthing  hospitals  (37) are aware of any program 
evaluation  by a child  support office.  This could be because child  support agency  monitoring 
of hospitals  is not done Statewide,  or that our respondents,  as frontline  staff,  are not made 
aware of the monitoring  or assessments  by hospital  administrators.  It is also possible  some 
State child  support agencies  are monitoring  hospital  activity,  but are not yet ready  to provide 
feedback  to hospitals  or plan to contact  hospitals  only  when problems  arise.  Regardless,  our 
6  hospital  respondents,  those directly  responsible  for contact  with unmarried  parents,  are 
usually  not aware of the results  of any monitoring  or assessment.  A companion  report 
subtitled  Best Practices  in Education  and Outreach  will describe  the efforts  of States which 
have begun to conduct  assessments  of hospital  process  as well as outcome,  and detail 
innovative  ideas for offering  feedback  to hospital  staff. 
RELATIONSHIPS  BETWEEN  KEY PLAYERS 
Most Birthing HospitalsReport Effective Relationshipswith VitalRecords and Are Also 
Fairly Positiveabout Child Support Agencies, But Often Have Trouble Identifying Them. 
Birthing  hospitals  and vital  records  agencies  report  positive  ties with each other,  enjoying 
long-standing  relationships  established  through  the birth  registration  process.  Eighty-one 
percent  of hospitals  and 93 percent  of vital  records  agencies  rate their  general  relationship 
with each other  as effective  or very  effective,  although  a few wrote their  relationship  did not 
reflect  work on paternity  acknowledgments  as their  vital  records  department  hadnt yet 
become  actively  involved  with this effort.  Only four percent  of hospitals  report  an 
ineffective  or very  ineffective  relationship  with their vital  records  agency.12  Seventy-six 
percent  of hospital  respondents  find no barriers  at all to this relationship,  but of those who 
did list barriers,  the most common  are poor  communication  (30 percent),  differences  in 
levels  of automation  (25 percent),  and inadequate  training  of hospital  staff by vital  records 
(24 percent). 
Conversely,  many birthing  hospitals  have difficulty  characterizing  a relationship  with their 
child  support agency.  Child  support agencies  in the sample States rate their  contact  with 
birthing  hospitals  as positive,  with 80 percent  reporting  effective  or very  effective 
relationships,  but 53 percent  of hospitals  claim  they have no relationship  with their  child 
support agency.  In addition,  nearly  a third  of hospitals  (35 percent)  report  that,  although 
they offer  acknowledgment  services  and inform  parents  about paternity,  they do not consider 
themselves  to be part of a Statewide paternity  acknowledgment  program.  Among high-
Medicaid  hospitals,  urbanization  affected  the perception  of participation  in a Statewide 
program:  53 percent  of high-Medicaid,  rural  hospitals  did not consider  themselves  part of a 
Statewide paternity  acknowledgment  program  contrasted  with 33 percent  high-Medicaid, 
urban  hospitals  and only  15 percent  of high-Medicaid,  suburban  hospitals.  It is important  to 
note that of the nearly  two hundred  birthing  hospitals  which did recognize  a relationship  with 
their  child  support agency,  73 percent  rate the relationship  as effective  or very  effective. 
Other hospital  responses  in part disprove  this reported  lack of a connection  with the child 
support office  and may point  instead to a misunderstanding  by hospital  respondents.  One 
cause of this claim  of no relationship  with child  support agencies  could  be hospitals 
difficulty  in identifying  the agency  name or paternity  program  name.13  Of those claiming 
no relationship,  nearly  half  went on in our survey  to identify  specific program  tasks which 
had been completed  by child  support personnel.  Also,  when a number  of hospitals  which 
report  no relationship  sent us their  completed  surveys,  they  included  outreach  and staff 
training  materials  which are clearly  produced  by their child  support agency.  Still,  large 
numbers  of hospital  respondents  reporting  no relationship  with a child  support agency 
7  signifies  child  support offices  may not be proactive  enough  in identifying  themselves  to 
birthing  hospitals.  When this occurs,  hospital  staff may have difficulty  requesting  additional 
materials  or program  assistance.  There  appears  to be a genuine  need for more  and better 
(particularly  interactive)  training  and outreach  to hospital  staff by child  support  agencies. 
Not only  would hospital  staff benefit  from the content  of the training,  but they  would begin 
to develop  ties to the child  support office  that would aid in further  program  collaboration. 
Part of the problem  birthing  hospitals  have  in identifying  their  States child  support agency 
may also be that both child  support and vital  records  agencies  are unclear  about their 
respective  roles  in the acknowledgment  process.  When asked which of the two State 
agencies  has primary  responsibility  for administering  the acknowledgment  process,  agencies 
in three  States gave different  answers.  It should  not be surprising  in these States that 
hospitals  have trouble  identifying  and distinguishing  agency  roles.  When hospital 
respondents  are able to identify  their  State or local child  support agency  and list barriers  to 
effective  collaboration,  they most often list poor  communication  (46 percent),  inadequate 
training  of hospital  staff by the child  support agency  (25 percent)  and difficulty  obtaining 
materials  and assistance  (18 percent).  One hospital  respondent  wrote that she would benefit 
from having  a single child  support staff member  serve as a contact  for her hospital,  and a 
few complain  that phone  lines were busy when they tried to call for more materials. 
Child Support Agencies  Which Pay Hospitalsfor  CompletedAcknowledgmentsReport This 
Enhances Relationships,But HospitalRespondentsAppear Largely Unaffected by Payment. 
Provisions  allow,  but do not require,  child  support agencies  to pay hospitals  an 
administrative  fee for completed  voluntary  paternity  acknowledgments.14  There  has been 
much policy  discussion  within  the child  support community  regarding  the appropriateness  of 
this payment  and its effect  on service  and relationships.  Of the  15 sample States,  eight child 
support offices  report  they currently  pay hospitals  for receipt  of completed  voluntary 
paternity  acknowledgments,  while one office  did pay in the past and six have never  paid. 
Not all of the States which pay responded  about the effect  of payment  on services,  but all 
five which did respond  report  an improvement  in hospital  service  and in their  relationship 
with hospitals  as a result  of payment. 
However,  16 percent  of hospitals  in States which pay do not report  receiving  such payments. 
In two States this discrepancy  is caused,  at least in part,  by the child  support agency  only 
paying  hospitals  on a per request basis,  indicating  that some hospitals  may not have known 
that payment  is available  or are not interested  in being paid.  Other discrepancies  may be 
because the frontline  hospital  staff responding  to our survey  may not be aware that payment 
is made to the hospital.  The remaining  seven States choose  not to pay primarily  because 
they consider  it the hospitals job  to process  birth  registration  information  and therefore  cant 
justify  payment  (4 States),  or they feel funds are too limited  to allow payment  (3 States). 
Although  child  support agencies  which pay believe  payment  helps hospitals  and improves 
relationships,  our hospital  respondents  report  payment  makes little difference.  Most hospital 
respondents  (77 percent)  claim the additional  funds make no difference  or only  a minimal 
difference  in their  hospitals  ability  to administer  voluntary  acknowledgments.  Nineteen 
8  percent  report  payment  by their child  support agency  makes a great to moderate  difference  in 

administration,  and the remaining  four percent  didnt  know  if it made a difference  to their 

hospital.  It could be that the money  does make a difference  to hospital  administrators  or 

comptrollers,  but payment  has less effect  on the frontline  workers  who actually  handle  the 

paternity  acknowledgments  and who completed  our survey.  Some hospital  respondents  who 

did report  the payment  makes a difference  cited the cost of staffing  notaries  as 

justification.  l5 At the time regulations  were written  to provide  guidance  for 

implementation,  policy  makers  expressed  a fear that hospital  payment  for acknowledgments 

would dilute the voluntary  nature  of the process  by providing  a bounty  for hospitals.  Our 

survey  results appear to disprove  this fear,  as frontline  workers  often report  being unaffected 

by and even unaware  of payment  agreements. 

ASSISTANCE  TO HOSPITAL  STAFF AND PARENTS 
Not All Hospitalsare Provided withStaff Training and Educational Materialsto Assist 
them in the AcknowledgmentProcess, and Even Though Most Child Support Agencies 
Report Producing Videos and Conducting On-Site Training Sessions, a Much Smaller 
Percentage of HospitalsReport Use of These Methods, Relying Primarilyon Brochures. 
Only 72 percent  of hospitals  report  receiving  staff training  or educational  materials  on 
paternity  acknowledgment  from one of the State agencies.  Sixty percent  of hospitals  report 
receiving  brochures,  but far fewer appear to be using more  interactive  methods  of staff 
training.  Even though  all child  support and vital records  agencies  in the  15 sample States 
report  they train hospital  staff,  and six child  support agencies  have produced  training  videos, 
only  18 percent  of hospitals  report  using videos  on the paternity  acknowledgment  process  for 
staff training. 
Additionally,  high percentages  (87 and 85 percent)  of both child  support and vital  records 
agencies  report  conducting  on-site  lectures  or seminars,  but only  23 percent  of hospitals 
report  receiving  such training  (See Table 2).  This discrepancy  could be because training 
sessions are often conducted  for the staff of several  birthing  hospitals  from the same region 
and were therefore  not identified  by hospital  survey  respondents  as on-site  training,  but is 
more likely  to be because  on-site  training  by agencies  has only  been completed  in a small 
number  of the States hospitals.  Child  support agencies  in sample States report  hospital  staff 
training  materials  are most often created by their  own staff (87 percent),  with additional 
materials  coming  from  vital  records  staff (20 percent),  and private  contractors  (27 percent). 
It is important  to note that although  all vital records  agencies  train  hospital  staff,  the focus of 
their  training  is usually  on the birth  registration  process  as a whole and not specifically  on 
paternity  acknowledgment  for unmarried  parents.  Since vital  records  agencies  must make 
contact  with hospitals  regarding  birth  registration  anyway,  it may be prudent  for child 
support staff to work within  this preexisting  framework  and collaborate  with vital  records  in 
distributing  paternity  materials.  PRWORA requires  that vital  records  agencies  offer  paternity 
acknowledgment  services,  both  in the hospital  and at their  State, regional  and local  offices. 
9 
 Table 2:  TYPE OF HOSPITAL STAFF TRAINING PROVIDED TO 
AND RECEIVED BY BIRTHING HOSPITALS 
Child Support  Vital Records  Hospitals 
Brochures/Pamphlets/Handbook  93%  54%  60% 
(14)  (7)  (242) 
On-Site Lectures  or Seminars  87%  85%  23% 
(13)  (11)  (106) 
Video Tape Training  40%  0%  18% 
(6)  (0)  (57) 
Other (examples:  regional workshops,  67%  40%  16% 
individual meetings, l-800 phone number,  etc.)  (10)  (6)  (68) 
Even Though Child Support Agencies Have Created Training Materials, They Are Not All 
Proactivein Determining Hospitals Training Needs and Hospitals Which Have Already 
Been  Trained by Child Support Agencies Still Express the Need for More Training. 
Significantly,  even many hospital  staff who received  training  do not yet feel comfortable 
administering  the program,  as 39 percent  of hospitals  reporting  they  need more training  have 
recently  been trained  by their  child  support agency.  Several  mentioned  a particular  desire  for 
interactive  training  methods,  such as videos,  seminars,  and on-site  visits.  We received  a 
number  of calls from hospitals  during  the survey  requesting  information  on video and 
seminar  resources,  and referred  them to their  State child  support  office.  When training  does 
take place,  it targets hospital  birth  registrars  primarily,  but often  includes  obstetrics  staff,  and 
to a lesser degree,  medical  social  workers,  nursery  attendants  and pediatrics  staff.  Hospital 
staff training  by child  support agencies  covers  only  paternity  acknowledgment  issues,  but as 
mentioned  above,  training  by vital records  agencies  must focus on the larger  birth 
registration  process.  Some (20 percent)  vital  records  agency  training  of hospital  staff does 
not include  information  on voluntary  paternity  acknowledgment  at all. 
Even when initial  training  efforts  are made,  hospital  staff turnover  and high  numbers  of 
nonmarital  births  create  a continual  need for assistance.  Adequate  aid to hospitals  requires 
that child  support agencies  determine  changing  hospital  needs,  but not all child  support 
agencies  make this effort.  After  initial  training  efforts,  child  support  offices  in six sample 
States (40 percent)  rely on hospitals  to notify  them when there  is a need for additional 
instruction  and materials  for new hospital  employees,  and make no effort  to initiate  contact 
with hospitals  or assess their  continuing  needs.  A few hospital  respondents  wrote that they 
would appreciate  these contacts  as a means of  moral support. 
Among  the remaining  nine child  support  agencies  which use more proactive  methods  to 
determine  need,  53 percent  place periodic  phone  calls,  and 47 percent  conduct  status checks 
in-person.  Only  13 percent  of child  support agencies  in sample States automatically  send 
new materials  throughout  the year.  A small number  of hospitals  (5 percent),  have begun to 
10 
 create  their  own paternity  acknowledgment  training  materials,  usually  simple  step-by-step 
instruction  sheets. 
Some Child Support Agencies and HospitalsConduct Follow-upAfter Discharge With 
Parents Who Do Not Acknowledge PaternityDuring Their HospitalStay, But Some States 
Have PrivacyStatutes Which Inhibit Such Efforts. 
Because hospital  stays are often brief,  and births  may not be registered  for a week or more, 
three  child  support agencies  and  19 percent  of hospitals  in sample States contact  all 
unmarried  mothers  following  discharge  if they do not voluntarily  acknowledge  paternity  in 
the hospital.  The purpose  of these contacts  is to offer  mothers  another  opportunity  for 
assistance  in acknowledging  paternity  before  the birth  is registered.  Typical  is a phone call 
or certified  letter a week or more after discharge. l6  Child  support offices  most often 
receive  the birth  registration  information  necessary  for these follow-ups  from  the State or 
local vital  records  agencies.  Hospitals  simply  use the birth  registration  information  they 
collect  during  the hospital  stay.  This follow-up  is conducted  irrespective  of the familys 
child  support status, but at least three  of the sample States possess privacy  statutes which 
would  inhibit  child  support  staff from  receiving  birth  registration  information  such as phone 
numbers  and addresses  from unmarried  parents  not in the child  support caseload.  No vital 
records  agency  reports  use of a follow-up  procedure. 
Nearly All Child Support Agencies in Sample States Report Educational Outreach Efforts 
to Parents (93 percent), but Fewer Hospitals(74 percent) Report Such Materialsare 
Availableand Utilized,and Only a Quarter of HospitalsConduct Prenatal Outreach. 
All but one sample child  support agency  report  participating  in outreach  to parents  regarding 
voluntary  paternity  acknowledgment,  and the remaining  State was creating  an outreach 
program  when surveyed.  Among  child  support offices  which distribute  parent  outreach 
materials,  brochures  and pamphlets  are the most common  outreach  mechanism  created  (100 
percent),  followed  by videos  (79 percent),  and workshops  or lectures  (7 1 percent).  See 
Table 3 for a complete  listing.  Most (86 percent)  of these States offer  materials  in languages 
besides English,  with Spanish being the most common  alternative.  As with hospital  staff 
training,  child  support agencies  report  their  own staff create these materials  most frequently 
(86 percent),  and that private  contractors  create  additional  materials  in 36 percent  of sample 
States. 
11 
 Table 3:  TYPE OF PARENT OUTREACH 

PROVIDED TO AND USED BY BIRTHING HOSPITALS 

Child Support  Birthing  Hospitals 
Brochures/Pamphlets/Handbook 
 100%  67% 
(14)  (195) 
Video Tape Training 
 79%  23% 
(11)  (60) 
On-site Lectures  or Workshops 
 71%  2% 
(10)  (7) 
Other (examples:  regional workshops, 
 67%  6% 
individual meetings, l-800 numbers,  etc.)  (10)  (18) 
Though  nearly  all child  support agencies  report  producing  and distributing  these materials, 
just  74 percent  of responding  hospitals  are prepared  with educational  materials  for unmarried 
parents,  usually  a brochure  or paternity  instruction  packet  (67 percent).  Although  a high 
number  of child  support offices  produce  videos and hold  workshops  for parents,  only  a 
quarter  of hospitals  (23 percent)  report  using  videos  and only  seven hospitals  report 
holding  workshops.  The discrepancy  between  agency  reported  outreach  efforts  conducted 
and those materials  actually  being used in the hospital  suggests that child  support offices  have 
often not distributed  materials  Statewide,  they  are not conducting  follow-up  to provide  a 
continual  supply  of materials  as mentioned  above,  or that hospital  staff are not using the 
materials  sent.  In the case of the outreach  workshops  or lectures,  child  support  offices  which 
report  use of these must have thus far reached  only  a very  small number  of their  States 
hospitals.  When  materials  are widely  distributed,  lack of use could  indicate  a hospital 
administration  problem  in which materials  received  are not properly  distributed  to frontline 
hospital  staff for use with parents. 
Hospital  staff not using available  parent  educational  materials  may be a result  of insufficient 
program  training  on the part of the State child  support or vital  records  agencies.  During 
preinspection,  one birth  registrar  in a large public  hospital  searched  her office  for a lengthy 
period  following  our request  for materials,  and eventually  uncovered  a large  package  of 
brochures  sent to the hospital  by the State child  support agency.  She had been given no 
instruction  on use of the materials,  and so had packed the brochures  away as unimportant. 
In addition,  only  20 percent  of hospitals  conduct  any prenatal  education  on voluntary 
paternity  acknowledgment,  although  a third  of both child  support  and hospital  respondents 
believe  this prenatal  education  is important  for encouraging  unmarried  parents  to 
acknowledge. l8  Several  sample States have begun more  widespread  outreach  efforts,  and in 
a companion  report  we will provide  details  regarding  the variety  of educational  outreach 
techniques  which  States and hospitals  use in their  voluntary  paternity  acknowledgment 
programs. 
12 
 ADDITIONAL  PROGRAM  CONSTRAINTS 
Over Half of HospitalsPerceive No Barriers to Implementation,Although the Qualityof 
HospitalServices is Reported to be Limited Somewhatby Internal HospitalFactors Such as 
Insufficient Staffing Levels, and Over-Relianceon Birth Certificate Worksheets. 
Collaboration  between  State agencies  and birthing  hospitals  is critical  to the success of 
voluntary  paternity  acknowledgment  programs,  but a number  of factors  inherent  in birthing 
hospitals  may somewhat  hamper  program  efforts.  Child  support agencies  indicate  a number 
of barriers,  including  lack of sufficient  hospital  staff (80 percent),  staff not recognizing  the 
importance  of their  role  (80 percent),  and staff being  inflexible  and resistant  to change  (33 
percent).  Vital  records  agencies  agree  strongly  that the lack of hospital  staff is an internal 
facility  constraint  (47 percent).  Sample vital records  agencies  unanimously  identify  the 
inability  of hospital  staff to perceive  a need for the program  as a barrier,  although  far fewer 
sample child  support agencies  (40 percent)  agree.  This concern  is not born  out by the 
hospital  survey,  as 87 percent  of hospital  respondents  report  at least a moderate  need for 
paternity  services  in their  hospitals,  and 55 percent  even claim  a great or very great need.  A 
quarter  of vital  records  agencies  (27 percent)  find no barriers  at all to hospital  participation 
(See Table 4). 
Table 4:  BARRIERS TO HOSPITAL PARTICIPATION 
Child Support  Vital Records 
No Barriers  Found  7%  27% 
(1)  (4) 
Hospital Understaffed  to Deal with the Acknowledgment  Process  80%  47% 
(12)  (7) 
High Staff Turnover  Limits Knowledge  and Expertise  N/A  64% 
(9) 
Staff Doesnt Recognize  the Importance  of Their  Role  80%  13% 
(12)  (2) 
Staff Perceive  No Need For the Program  in Their Hospitals  40%  100% 
(6)  (14) 
Staff is Inflexible  and Resistant to Change  33%  7% 
(5)  (1) 
Little or No Payment to Hospitals by Child Support  7%  N/A 
(1) 
An additional  potential  barrier  to effective  parental  involvement  is possible  over-reliance  on 
birth  certificate  worksheets.  Eighty-four  percent  of responding  birthing  hospitals  use birth 
certificate  worksheets  to obtain  registration  information  from  new parents,  and the use of 
these worksheets  may limit communication  between parents  and staff.  We placed follow-up 
telephone  calls to a number  of hospitals  which report  using birth  certificate  worksheets,  and 
find that they may considerably  reduce the amount  of time parents  interact  with hospital  staff 
13  such as birth  registrars  and obstetrics  nurses.  Hospital  staff typically  leave the worksheet 
with the unmarried  mother  for completion  (possibly  along  with a brochure  on paternity 
acknowledgment),  and pick  it up just  prior  to patient  discharge. l9 In hospitals  where 
worksheets  are not used,  hospital  staff ask birth certificate  questions  of the mother  directly. 
When  asking questions  pertaining  to the father,  staff who interview  orally  rather  than using 
worksheets  have a natural  opportunity  to inform  the mother  of the acknowledgment  process. 
A heavy  reliance  on birth  certificate  worksheets  may prove  especially  problematic  under the 
PRWORA  provision  requiring  hospital  staff to give both written  and oral notification  of 
paternity  rights  and responsibilities. 
Over half  (54 percent)  of responding  birthing  hospitals  saw no internal  barriers  to 
participation  in their  States voluntary  paternity  acknowledgment  program,  although  many 
hospital  respondents  do agree with agencies  that sufficient  staffing  can be a problem. 
Of those hospitals  identifying  facility  barriers,  the most common  are lack of sufficient 
hospital  staff (37 percent),  paternity  acknowledgment  being  given  a low priority  by hospitals 
(24 percent),  and hospital  budget constraints  (18 percent).  Of hospital  respondents  who did 
perceive  facility  barriers,  half  report  only  one barrier,  while 20 percent  report  two barriers, 
25 percent  report  three,  and only  5 percent  find four or more barriers,  suggesting  that 
hospitals  respondents  feel fairly  positive  about the capability  of their hospital  to administer 
the program.  During  our preinspection  interviews,  child  support personnel  often mentioned 
high hospital  staff turnover  as a barrier  to program  implementation.  Although  64 percent  of 
vital  records  respondents  cite this as a barrier  (the child  support  survey  did not list this 
option),  few hospitals  (6 percent)  see high staff turnover  as a barrier  to program 
implementation. 
Half of Child Support Agencies and a Quarter of HospitalsReport Requiring Notarization 
of PaternityDocuments NegativelyImpacts the VoluntaryAcknowledgmentProgram, 
PrimarilyDue to Limited Availabilityof Notaries. 
Because most paternity  establishments  were formerly  completed  through  a judicial  process, 
notarization  of paternity  documents  is thought  by some to add credibility  to the new 
administrative  procedures.  Because notarization  of paternity  documents  requires  that 
hospitals  have access to certified  notaries  public,  the requirement  is a potential  barrier  to 
smooth program  operations.  Notarization  of paternity  acknowledgment  affidavits  is required 
in 11 sample States,  with the remaining  four requiring  witnessing  of paternity 
documentation.*  Only 23 percent  of hospitals  in notarizing  States report  the requirement 
has an overall  negative  impact,  with 36 percent  claiming  a positive  impact,  and the remaining 
40 percent  reporting  no impact.  Suburban  hospitals  are more  likely  to report  a positive 
impact (46 percent)  compared  with both urban  and rural  hospitals  (36 and 32 percent). 
Although  the reaction  to notarization  is not strongly  negative,  over half (57 percent)  of 
hospitals  which  require  notarization  did indicate  that unavailability  of notaries  can be a 
barrier  to acknowledgment.  But of the 57 percent  of hospitals  which  report  lack of 
availability  of notaries  as a problem,  two-thirds  (66 percent)  claim  notarization  has a positive 
impact or no impact on their programs.  It may be that some birth  registrars  are burdened  a 
bit by the availability  issue, but still dont see notarization  as a negative  because they believe 
in its importance.  Comments  include,  requiring  a notary to sign the forms  makes me feel 
14  more comfortable in knowing that the forms  have been completed,  and parents take the 
process  more seriously and muy be more likely to understand  its importance. 
Child  support agencies  are more negative  than hospitals  on the issue of notarization.  Six 
child  support agencies  in the  11 sample States which  require  notarization  report  it has a 
negative  impact on their  programs,  four agencies  claim  a positive  impact and one reports  no 
impact.  Further,  most child  support agencies  which have chosen  to require  only  a witness 
cite the lack of availability  of notaries  as the reason.  These  agencies  appear to assume 
notarization  places  a greater  strain on hospital  staff than the hospitals  themselves  report.  A 
few hospitals  (12) say it is difficult  to have both the mother  and father  present  at the same 
time the notary  is available*,  and the father  may often lack proper  identification. 
Hospitals  perceiving  availability  of notaries  as a problem  often  note this can cause a delay  in 
signing,  with 40 hospitals  mentioning  evenings  and weekends  as particularly  problematic.  In 
64 percent  of responding  hospitals,  notaries  are available  only  during  weekday  business 
hours.  Another  11 percent  of hospitals  also report  notaries  are only  available  during  business 
hours,  but are on-call  at other times.  Only  six percent  of responding  birthing  hospitals  for 
whom notarization  was required  had notaries  on staff seven days a week,  24 hours  a day. 
The remaining  19 percent  gave a wide variety  of responses,  usually  indicating  notary  staffing 
changed from  day to day.  The availability  of notaries  is less likely  to affect the completion 
of acknowledgments  in rural  hospitals  (48 percent)  compared  with suburban  or urban 
hospitals  (65 and 63 percent).  While  9 percent  of responding  hospitals  require  completion  of 
acknowledgments  before  the mother  is released,  most hospital  birth  registrars  will accept an 
acknowledgment  affidavit  from parents  after discharge.** 
Lack of ClarityAbout the Responsibilitiesof HospitalStaff in Communicating with 
Unmarried Parents, Particularlyas it Concerns Their Role as Advocatesof Paternity 
Acknowledgment, Creates a DisparityAmong Hospitalsin Their Service to Parents. 
Hospitals  and State agencies  give varied  and inconsistent  answers  regarding  the 
responsibilities  of frontline  hospital  staff in assisting  unmarried  parents  through  the 
acknowledgment  process.  Our survey  outlines  three  areas of potential  hospital  staff 
responsibility:  acknowledgment  documentation;  parental  rights  and responsibilities;  and 
advocacy  of paternity  acknowledgment.  Based on the Federal  statutes,  the first two areas are 
clear responsibilities  of hospital  staff.  Hospital  staff obviously  must help to facilitate  the 
documentation  of voluntary  acknowledgments  and,  according  to OBRA and PRWORA,  must 
also inform  parents  of their  rights  and responsibilities.  However,  only  10 vital  records 
agencies  in the sample States identified  these two key tasks.  All sample child  support 
agencies  identify  documentation  assistance,  but two do not believe  explanation  of rights  and 
responsibilities  to be the role of hospital  staff (see Table 5). 
The third potential  area of responsibility  (hospital  staff acting  as advocates  of paternity 
acknowledgment)  is somewhat  controversial.  Some child  support  advocates  believe  that 
hospital  staff should not actively  urge or encourage  acknowledgment,  especially  if the 
hospital  is being paid for submitting  completed  forms,  as this may jeopardize  the voluntary 
nature of acknowledgment.  However,  10 child  support agencies  and 7 vital records 
15  respondents  in sample States support this more proactive  role by hospital  staff.  Of birthing 
hospitals,  38 percent  felt an obligation  to actively  urge or encourage  unmarried  parents  to 
acknowledge  paternity.  Interestingly,  high-Medicaid,  suburban  and urban  hospitals  are more 
likely  to actively  promote  the idea of paternity  acknowledgment  to parents  as a perceived  role 
of hospital  staff (63 and 47 percent)  compared  with low-Medicaid,  urban hospitals  (26 
percent).  Based on these divergent  responses,  it appears both State agencies  and hospitals 
are somewhat  confused  about the role of hospital  staff.  All key players  may benefit  from 
guidance  regarding  the content,  tone and tenor  of contact  between unmarried  parents  and 
hospital  staff.23  Unless both child  support and vital  records  agencies  construct  a unified  set 
of guidelines  and inform  their  own personnel,  as well as birthing  hospital  staff,  there  is less 
likelihood  that parents  will receive  a clear  and consistent  message on the voluntary 
acknowledgment  process. 
II 
Table 5:  ROLE OF HOSPITAL STAFF  II 
Child  Vital 
support  Records  Hospitals 
Informing  Parents of their Rights and Responsibilities  87%  71%  76% 
(13)  (10)  (317) 
Helping to Facilitate the Documentation  of Acknowledgment  100%  71%  59% 
(15)  (10)  (24% 
Actively  Urging or Encouraging  Parents to Acknowledge  67%  50%  38% 
(10)  (7)  (168) 
Factors External to HospitalPrograms, Such as Poor Parent Relationships,May Also 
Limit PaternityAcknowledgments,Although HospitalsReport Large Numbers of Fathers 
VisitDuring the Mothers Stay. 
The success or failure  of voluntary  paternity  acknowledgment  programs  lies ultimately  with 
the parents  themselves.  Both child  support agencies  and hospital  respondents  affirm  that the 
parent relationship  is crucial  in making  the decision  to acknowledge.  Hospitals  and child 
support agencies  largely  agree about what influences  parents  to acknowledge,  with both citing 
the putative  father  as slightly  more likely  than the mother  to create  a barrier  to 
acknowledgment.  Among  hospital  respondents,  57 percent  believe  it is most often the father 
who creates  a barrier  to acknowledging  paternity,  24 percent  report  the mother  and father 
equally  share responsibility  for not acknowledging,  and  19 percent  report  the mother  is most 
often reluctant. 24 Child  support agencies  cite a number  of factors  that have a strong or very 
strong influence  on whether  or not parents  choose  to acknowledge  paternity.  The most 
common  factors  influencing  parents  to acknowledge  include  the new parents  cohabitating  or 
in a long relationship,  their  exposure  to the idea of paternity  establishment  by hospital  staff, 
and strong emotional  feelings  upon the babys  arrival  (see Table 6). 
Not many differences  exist between child  support and hospital  staff responses  regarding  what 
influences  parents  to acknowledge,  but,  interestingly,  child  support agencies  are more  likely 
than hospital  respondents  to credit parental  exposure  to the idea of paternity  acknowledgment 
16  by hospital  staff.*  Hospitals  are much more likely  than child  support to mention  the 
influence  of both maternal  and paternal  grandparents.  Even though  it was not provided  as an 
option  on our survey  instrument,  a number  of hospital  respondents  wrote that naming  the 
father  on the birth  certificate  is also an incentive  for parents  to acknowledge. 
Table 6:  Factors Reported to Strongly  or Very Strongly  Influence 
Unmarried  Parents to Acknowledge  Paternity  at the Hospital 
Child Support  Hospitals 
New parents cohabitating  or in long relationship  80%  82% 
(12)  (258) 
Emotional feelings with babys arrival  68%  75% 
(10)  Gw 
Exposure  to idea of paternity  from hospital staff  68%  41% 
(10)  (161) 
Exposure  to idea of paternity  33%  33% 
from prenatal care providers  (5)  (63) 
Pressure  from paternal grandparents  14%  28% 
(2)  (56) 
Pressure  from maternal grandparents  14%  39% 
(2)  (85) 
Factors  having  the greatest  influence  on parents  who choose  not to acknowledge  include  a 
bad relationship  between  the new parents,  the putative  father  not visiting  the hospital,  the 
new mothers  fear of sharing  custody,  and the short  length  of her hospital  stay (see Table 7). 
The closest  agreement  between  agencies  and hospitals  is the mothers  fear of violence  from 
the father,  the father  not visiting  the hospital,  and the mothers  fear of losing  AFDC  and 
other public benefits.  However,  child  support agencies  give much more credence  than 
hospitals  to the effect  of parents  poor understanding  about paternity,  the length  of the 
mothers  hospital  stay*j, and the mothers  fear of losing  custody.  Again,  hospital 
respondents  affirm the significance  of both paternal  and maternal  grandparents.  Although  not 
listed as an option  on our survey  instrument,  several  hospital  respondents  wrote that fathers 
may not sign at the time of birth because they believe  they will then be responsible  for the 
hospital  bill.  Other negative  influences  mentioned  by hospital  respondents  were the fear of 
paying  child  support,  and uncertainty  about the identity  of the father. 
When the father doesnt  visit the hospital  it creates,  of course,  a strong  influence  against 
acknowledgment.  However,  most hospital  respondents  (68 percent)  estimate  all or most 
unmarried  fathers  come to the hospital  during  the mother  and babys hospital  stay.  Another 
22 percent  estimate  that about half of unmarried  fathers  come,  and only  five percent  report 
few or no fathers  come to the hospital. 27 Rural,  low-Medicaid  hospitals  experience  the 
greatest  number  of fathers  visiting  the hospital  (82 percent)  compared  with 68 percent  of all 
suburban  hospitals  and 61 percent  of all urban  hospitals.  Father  visitation  is lowest in high-
17 
 Medicaid  urban hospitals  compared  with other hospital  types,  with only  52 percent  of these 
hospitals  report  that all or most fathers  come to the hospital.  Forty-five  percent  of all 
hospital  respondents  estimate  that most or all of these fathers  who visit also participate  in the 
labor  and delivery  process,  with another  25 percent  reporting  about half of unmarried  fathers 
participate  and 11 percent  claiming  only  a few or no fathers  participate.28  Therefore,  a 
relatively  large number  of fathers  appear to be present  during  the hospital  stay but still 
choose  not to acknowledge  paternity. 
Table 7:  Factors Agencies Report to Strongly  or Very Strongly Influence 
Unmarried Parents Not to Acknowledge  Paternity  at the Hospital 
Child Support  Hospitals 
Bad Relationship Between the Unmarried  Parents 
 100%  75% 
(15)  (253) 
Father Doesnt Visit the Hospital 
 87%  76% 
(13)  (246) 
Mothers Fear of Sharing Custody With the Father 
 87%  42% 
(13)  (128) 
Length of the Hospital Stay Short 
 80%  41% 
(12)  (131) 
Lack of Understanding  About Paternity  Establishment 
 60%  31% 
(9)  (104) 
Mothers Fear of Not Receiving AFDC or Other Benefits 
 50%  61% 
(7)  (180) 
Mothers Fear of Violence  From Father 
 46%  36% 
(6)  (74) 
Pressure From Maternal Grandparents 
 8%  26% 
(1)  (56) 
Pressure From Paternal Grandparents 
 8%  20% 
(1)  (41) 
18 
 RECOMMENDATIONS 
Overall,  we find hospitals  are supportive  of the paternity  acknowledgment  effort,  appear to 
recognize  the importance  of paternity  establishment,  and are increasingly  capable  of 
successfully  administering  acknowledgments.  However,  State agencies,  particularly  child 
support,  could do more  to assist hospitals  in program  administration.  Based on our findings, 
we recommend  the Office of Child  Support Enforcement  (OCSE) take the following  actions 
to improve  the State operation  of in-hospital  paternity  acknowledgment  programs.  The first 
and second recommendations  duplicate  those found in a companion  report  on nationwide 
program  implementation: 
AGENCY  INTERACTION AND DIVISION  OF DUTIES.  Promote  interagency 
collaboration,  and assure child support and vital records agencies  more clearly define 
their respective  agency roles.  In a number  of States, hospital  staff do not understand  the 
responsibilities  of the two respective  agencies.  Over half  of hospital  respondents  couldnt 
even identify  their  child  support agency,  and a number even called  our office  for assistance 
after receiving  their  survey.  This confusion  could create  delays  in documentation,  as well as 
gaps in service  to hospitals  and in outreach  to unmarried  parents.  OCSE should provide 
technical  assistance  to enhance  agency  interaction  and encourage  joint  problem-solving 
among child  support  and vital  records  agencies,  and should consider  encouraging  States to 
draft  a flexible  interagency  agreement  which  would make clear  the procedures  and activities 
specific  to each agency.  Such an agreement  may help to provide  hospitals  with a clear 
contact  point,  avoiding  possible  duplication  of effort,  developing  efficient  administrative 
mechanisms  and maximizing  the use of State and Federal  resources. 
STATEWIDE HOSPITAL IMPLEMENTATION AND ASSESSMENT.  Monitor  Statewide 
hospital implementation  by assuring  all States collect acknowledgment  and nonmarital 
birth data for each birthing  hospital  and by encouraging  development  of hospital 
assessment procedures.  Although  nearly  all sample child  support  agencies  have contacted 
their birthing  hospitals  regarding  the Federal  mandates,  only  73 percent  report  Statewide 
hospital  participation.  In addition,  we find that programs  vary  widely  among hospitals  even 
in States which have achieved  Statewide  compliance.  Only 73 percent  of child  support 
agencies  in sample States have implemented  hospital  monitoring  procedures  by collecting 
data on the number  of acknowledgments  received  per hospital  and comparing  it to the 
number  of nonmarital  births  each hospital  assists.  OCSE should consider  developing  a 
uniform  reporting  mechanism  for States to record  data collected  for each birthing  hospital. 
OBRA requires  States at a minimum  collect  this data on hospital  nonmarital  births  and 
acknowledgments  received,  but States should be encouraged  to also assess hospital  practices 
and procedures  in obtaining  these acknowledgments.  OCSE should provide  technical 
assistance  to States in creating  hospital  assessment  procedures,  and in doing  so consider 
developing  assessment  criteria  which  would evaluate  the process  birthing  hospitals  use to 
obtain  acknowledgments  as well as the outcome of acknowledgments  received.  Examples  of 
potential  assessment  criteria  include  use of hospital  staff training  and outreach  materials, 
hospital  staff contact  with unmarried  parents,  and documentation  handling.  Not only  are 
many  hospitals  often not monitored  in their program  participation,  but few child  support 
19  offices  conduct  follow-up  efforts  to determine  continuing  hospital  needs.  A uniform  State 
reporting  mechanism  would serve to determine  State compliance  with the hospital  data 
collection  requirement,  allow  OCSE to monitor  Statewide  program  implementation,  and 
would  also hold child  support  agencies  more  accountable  for responding  to the needs of every 
hospital. 
DEFINITION  OF HOSPITAL ROLE.  Clarify the appropriate  role of birthing  hospital 
staff in providing  acknowledgment  assistance to unmarried  parents.  Both agencies  and 
hospital  staff members  are unclear  about the content  and tone of hospital  contact  with 
unmarried  parents.  Lack of clarity  about the responsibilities  of hospital  staff in 
communicating  with unmarried  parents,  particularly  as it concerns  their  role as potential 
advocates  of voluntary  paternity  acknowledgment,  creates  a disparity  among hospitals  in their 
service  to unmarried  parents.  Unless both child  support and vital  records  agencies  construct 
a unified  set of guidelines  and inform  their  own personnel  as well as birthing  hospital  staff, 
there  is less likelihood  that parents  will receive  a clear,  repetitive  and singular  message  on 
the voluntary  acknowledgment  process.  OCSE should help States to determine  the desired 
role  of hospital  staff,  and provide  guidance  to State child  support  agencies  in educating  staff 
accordingly. 
AGENCY  ASSISTANCE  TO HOSPITALS.  Encourage  State child support and vital records 
agencies to more actively  support hospital staff in implementing  acknowledgment 
programs.  OCSE should provide  technical  assistance  to child  support and vital  records 
agencies  which  would focus on providing  better  service  to hospitals,  including  aid in 
addressing  issues which create barriers  to program  services.  OCSE should also create  and/or 
distribute  sample hospital  staff training  and parent  outreach  materials,  including  interactive 
methods,  to give focus to State and hospital  educational  efforts.  These educational  materials 
should be accompanied  by instructions  or ideas which  would help States to ensure  the 
materials  are actually  used by hospital  staff and distributed  to unmarried  parents.  Because 
many  hospitals  in States which provide  materials  do not use these resources,  we know that 
creation  and perfunctory  distribution  to hospitals  does not guarantee  use. 
AGENCY COMMENTS 
We have worked  in close partnership  with OCSE throughout  the conduct  of this inspection. 
Although  we did not receive  formal  comments  from ACF  on our draft reports,  they 
demonstrated  through  their  collaboration  a general  agreement  with this report  and the 
companion  reports.  We worked  with OCSE in developing  a research  methodology,  provided 
extensive  briefings  on study findings  and created  additional  documents  to meet agency  needs. 
We appreciate  their  cooperation  and guidance,  and will continue  to work with them on the 
issues raised  in these reports.  The Office of the Assistant  Secretary  for Planning  and 
Evaluation  provided  its general  concurrence  with both this report  and the state 
implementation  report. 
20 
 ENDNOTES 

1. 	 A birthing  hospital  is a hospital  which  has an obstetric  care unit or provides 
obstetric  services,  or a birthing  center  associated  with a hospital.  (Federal 
Register,  Vol.  59, No.  246). 
2. 	 Within  each stratum  (high-Medicaid  and low-Medicaid),  we disproportionately 
sampled 20 birthing  hospitals  from  each State.  In a few cases,  States had less 
than 20 birthing  hospitals  within  each stratum.  In those  cases,  we sampled all 
hospitals  that met our criteria.  Hospital  survey  responses  were weighted  to 
reflect  the correct  proportion  of birthing  hospitals  within  each stratum.  All 
charts  list the weighted  percentages  and the unweighted  number  of respondents 
in parentheses. 
3. 	 Sample  states include  Alabama,  Arkansas,  California,  Colorado,  Florida, 
Illinois,  Kentucky,  Massachusetts,  Michigan,  Minnesota,  Missouri, 
Pennsylvania,  Texas,  Virginia,  and Washington. 
4. 	 Child  support and vital  records  agency  surveys  were received  between  April 
and August of  1996. 
5.  Birthing  hospital  surveys  were received  between  June and November  of 1996. 
6. 	 A number  of hospitals  listed more than one department  as having primary 
responsibility,  so percentages  equal greater  than one hundred.  One hospital 
which  shares responsibility  between  the obstetrics  and medical  records 
departments  reports  interdepartmental  collaboration  by using a paging  system 
wherein  obstetrics  nurses alert the birth  registrar  when the father  comes to 
visit  mother  and baby  so the registrar  may then introduce  the paternity 
affidavit. 
7. 	 When  staff did express  reluctance,  they  often cited lack of time to perform 
acknowledgment  duties and occasionally  wrote they believe  paternity  is too personal 
an issue to discuss with patients.  One obstetric  nurse reports  that discussing  paternity 
casts a  judgmental shadow over her relationship  with patients  during  the hospital 
stay. 
8. 	 This difference  could  reflect  the greater  need for paternity  acknowledgment  services 
in these hospitals  and the additional  challenge  this creates  in training  staff and 
allocating  resources  for the program. 
9, 	 Regulations  written  to interpret  OBRA 93 require  States to assess each 
birthing  hospitals  program  on at least an annual  basis  (Federal  Register,  Vol. 
59, No.  246).  This  assessment  requirement  specifies  only  the collection  of 
data on nonmarital  births  assisted and acknowledgments  received  per hospital. 
Following  consultation  with OCSE,  we use in this report  the phrase  monitor 
21  hospital  participation  to refer  to this type of data collection.  The term 
hospital  assessment  refers to a broader  effort  which  would include  the 
evaluation  of hospital procedures  as well as outcomes. 
10.  One benefit  of child  support offices paying  hospitals  for the processing  of 
acknowledgments  is that the financial  transaction  required  guarantees  a natural  count 
or tracking  of acknowledgments  per birthing  hospital. 
11.  At the time of data collection,  one sample vital  records  agency  played  no role in 
administering  its States voluntary  acknowledgment  program. 
12.  Suburban  hospitals  are less likely  to report  their  relationship  with vital  records 
agencies  as effective  or very effective  (72 percent)  contrasted  with urban and rural 
hospitals  (85 and 84 percent). 
13.  Birthing  hospital  respondents  were given  latitude  in identifying  their  child 
support office  for our survey.  For example,  if they used the agencys 
departmental  name  such as Social Services  instead of  Child  Support 
Office,  we credited  them as having  identified  the correct  office. 
14.  Payments  may be made up to $20 to birthing  hospitals  and other entities  that 
provide  prenatal  or birthing  services  for each voluntary  acknowledgment 
obtained  pursuant  to an agreement  with the child  support agency  (Federal 
Register,  Vol.  59, No.  246). 
15.  One birthing  hospital  writes that their  staff notaries  were paid directly  by hospital 
administration,  each receiving  $7 of the $20 fee charged  to child  support for their 
services  in notarizing  paternity  affidavits. 
16.  Occasionally  hospital  staff members  were more proactive  in conducting  follow-up 
with mothers  who did not acknowledge.  For example,  one respondent  in California 
writes that he places  phone  calls to the mothers  on a daily  basis prior  to birth 
registration  to check  for understanding  and encourage  acknowledgment,  and another 
in Massachusetts  writes that she makes appointments  with parents  to come back to 
sign the form. 
17.  One hospital  respondent  reports  that videos are a particularly  important  medium  for 
parent  outreach  because the reading  skills of some parents  do not enable them to 
comprehend  written  materials. 
18.  A number  of hospital  respondents  emphasize  the importance  of prenatal  outreach, 
writing  that  Mothers listen to their prenatal  care providers,  and  Parents often 
dont know the dejinition of the word paternity when they come to the hospital. 
19.  Hospitals  or prenatal  care providers  may distribute  birth  certificate  worksheets prior 
to admittance,  but at least one hospital  respondent  reports  that these are rarely 
returned. 
22 
 20.  The child  support agency  from  one of the  15 sample states did not respond 

when asked about notarization. 

21.  Not all State voluntary  paternity  acknowledgment  affidavits  include  space for 

separate  notary  seals for the mother  and fathers  signatures,  although  a 

Paternity  Affidavit  Taskforce  formed  by OCSE following  passage of 

PRWOILA has recommended  all States begin to allow  space for two seals. 

22.  These registrars  allow parents  from  one to ninety  days to return  to the hospital 

for assistance  in completing  acknowledgments,  with five days being the most 

common  grace period.  In addition,  parents  in all sample States may bring  the 

form  directly  to the local  or State vital  records  offices  at any point  following 

the childs  birth.  Hospital  staff may need more complete  information 

regarding  birth  registration  and paternity  documentation  so they  may refer 

parents  who do not acknowledge  during  the hospital  stay to the appropriate 

public  offices. 

23.  A few hospital  respondents  write they may occasionally  risk violence  when 

communicating  with parents,  particularly  when they tell the parents  that notarization 

of the paternity  form  will require  the father  to present  identification  or when the 

husband  is not the childs  father.  One birth  registrar  contributed  the following:  1 

am finding  a marked increase in complicated  social circumstances.  Often violent 
behavior  is involved  with these situations.  There have been times I have felt 
endangered  because  of the reacti#onsof the parents.  . .  
24.  Sometimes  the father  may be labeled  as creating  a barrier  by not visiting  the hospital, 
when it is actually  the mother  who is refusing  to allow  him to participate  and 
acknowledge  paternity.  One birth  registrar  writes,  If there is a strained  relationship 
between parents,  it is the mother who doesnt want the father  listed or who can 
actively prevent  (the) father from  acknowledging  paternity  by providing  no 
information,  and a child  support agency paternity  coordinator  calls mothers,  the 
gatekeepers  of paternity  information.  
25.  This  finding  replicates  data from  Table 4 that indicates  80 percent  of child 
support agencies  believe  hospital  staff do not recognize  the importance  of their 
role in communicating  with unmarried  parents. 
26.  Regarding  the length  of hospital  stay being too short to complete  paternity 
acknowledgment,  one obstetric  nurse writes,  Mom and dad have too many emotional 
and educational  demands at that time to focus  on something  they may perceive  as 
unimportant.  
27.  Some fathers  may not visit during  the mothers  hospital  stay,  but may come in on 
subsequent  days to sign the acknowledgment  before  the birth  is registered.  However, 
these post-discharge  appearances  by fathers  may not materialize  as often  as hospital 
staff would like.  One respondent  writes,  We have held many a certificate  to the time 
limit because  the mother thought she could get the dad to come in to sign.  
23  28. 	 High-Medicaid,  urban  hospitals  again had the lowest rate of father 
participation,  with only  37 percent  reporting  all or most fathers  participate 
during  labor  and delivery  contrasted  with 48 percent  of all other  hospitals. 
24 
 APPENDIX  A 
COMPARISON  OF  SAMFLE  AND  NON-SAMPLE  STATES 
The fifteen  States selected for the hospital-level  analysis  differed  significantly  from  non-
sample States in both  structural  and perceptual  ways based on child  support responses  (see 
Table  1 below).  The most striking  differences  deal with payment  issues,  barriers  to 
relationships  with vital  records  and hospitals,  monitoring  of hospital  participation,  training 
and training  materials,  and ratings  of hospitals  and acknowledgment  programs. 
Sample States are more likely  to pay both vital  records  and hospitals  for their  help in 
administering  the hospital  acknowledgement  programs  compared  to non-sample  States. 
Specifically,  sample States are over twice as likely  (57 vs. 25 percent)  to pay vital  records 
than those in the non-sample  States and also to report  that the payment  improved  their 
service  with vital  records.  Likewise,  child  support respondents  from  sample States are twice 
as likely  (79 vs.  37 percent)  to believe  they  should pay vital records  for their  assistance  than 
non-sample  States.  In addition,  53 percent  of sample States currently  pay fees to hospitals 
per acknowledgment  compared  with only  25 percent  of non-sample  States. 
Child  support agencies  in sample States also differ  in their  relationship  with both vital 
records  and hospitals.  Fifty  percent  of them report  no barriers  in dealing  with vital  records 
compared  with 22 percent  of non-sample  States.  However,  only  seven percent  of the child 
support agencies  in the sample States find there  are no barriers  in their  relationship  with 
hospitals  as opposed  to 29 percent  of the non-sample  States.  Sample States are also more 
likely  (93 vs.  66 percent)  to track  the number  of acknowledgments  per hospital  compared 
with non-sample  States and to monitor  hospital  participation  (73 vs. 44 percent). 
All of the child  support agencies  surveyed  in the sample States provide  training  for hospital 
staff compared  with  86 percent  of non-sample  States and 87 percent  provide  on-site  training 
in comparison  with 58 percent  of non-sample  States.  In addition,  40 percent  of sample State 
child  support agencies present  a training  video  to the hospital  staff compared  with only  29 
percent  of non-sample  States.  Child  support agencies  in sample States also report  more 
proactive  follow-up  with hospitals,  and are more likely  to make a phone  call or in-person 
visit to hospitals  to check on the supply of hospitals  training  materials.  Sample States are 
also at least twice as likely  (79 vs.  39 percent)  to provide  an educational  video  for training 
parents,  in-person  instruction  for parents  (71 vs.  32 percent),  and training  in other  languages 
(86 vs. 43 percent)  than non-sample  States. 
Additionally,  child  support agencies  are much less likely  to rate the hospitals  ability  (8 vs. 
25 percent)  and effort  (8 vs.  31 percent)  in administering  the paternity  acknowledgment 
program  as excellent  compared  with non-sample  States.  However,  they  find a greater 
number of advantages  in the program  for parents. 
A-l  Table  1:  DATA  OF CHILD  SUPPORT  AGENCIES 
Sample  Non-Sample 
Key  Questions  states  states  Overall 
Pavment  Issues 
Child  Support  Respondent  Believes  They  Should  Pay  Vital  79%  37%  49% 
Records  (11)  (13)  (24) 
Child  Support  Currently  Pays  Vital  Records  57%  25%  34% 
(8)  (9)  (17) 
Payment  Has  Improved  Service  With  Vital  Records  100%  44%  69% 
(7)  (4)  (11) 
Child  Support  Pays  Fees  to Hospitals  Per  Acknowledgment  53%  25%  33% 
(8)  (9)  (17) 
Barriers  to RelationsbiDs 
Reported  &  Barriers  With: 
Vital  Records  50%  22%  30% 
(7)  (8)  (15) 
Hospitals  7%  29%  22% 
(1)  (10)  (11) 
Monitoring  of Hosuital  ParticiDation 
Track  # of Acknowledgments  Per  Hospital  93%  66%  74% 
(14)  (23)  (37) 
Monitor  Hospitals  by  Comparing  Acknowledgments  Received  to  73%  44%  53% 
Births  Assisted  (11)  (16)  (27) 
TrainindTrainiw  Materials 
Provided  to Hospital  Sta# 
Child  Support  Training  100%  86%  90% 
(14)  (31)  (45) 
On-Site  Training  87%  58%  67% 
(13)  w9  (31) 
Training  Video  40%  29%  33% 
C-9  (9)  (15) 
Proactive  Follow-up  With Hospitals: 
By Phone  53%  30%  38% 
(8)  (10)  (18) 
In-Person  47%  27%  33% 
(7)  (9)  (16) 
Provided  to Parents: 
Educational  Video  79%  39%  51% 
(11)  (12)  (23) 
In-person  Instruction  71%  32%  44% 
(10)  (10)  (20) 
A-2 
 Table  1:  DATA  OF CHILD  SUPPORT  AGENCIES 
Sample  Non-Sample 
Key  Questions  states  states  Overall 
Training/Trainim  Materials 
Provided  to Parents:  86%  43%  57% 
Materials  in Other  Languages  (12)  (13)  (25) 
Ratings  of Hospitals  & Acknowledgment  Program 
Rating  of Hospitals  Ability: 
Excellent  8%  25%  20% 
(1)  (7)  (f3) 
Rating  of Hospitals  Effort: 
Excellent  8%  31%  23% 
(1)  (8)  (9) 
Advantages/Disadvantages  of Program  for  Parents: 
Find  Five  or More  Advantages 
87%  67%  73% 
(13)  (24)  (37) 
Find  Only  One  Disadvantage  40%  44%  43% 
(6)  (16)  (22) 
A-3 
 APPENDIX  B 
COMPARISON  OF  HOSPITAL  SURVEY  DATA  BY URBANIZATION  AND 
MEDICAID  DISCHARGE  RATES 
Birthing  hospital  survey  data from  our  15 Sample States were analyzed  by whether  they are 
located  in urban,  suburban  or rural  areas and by their Medicaid  discharge  rate.2  The 
Medicaid  discharge  rate  served as a proxy  for identifying  birthing  hospitals  which may have 
a larger  number  of unmarried  or low-income  clients.  We constructed  four  separate variables 
for this analysis;  one for urbanization;  one for Medicaid  discharge  status; one comparing 
high-Medicaid,  urban hospitals  to all others;  and one comparing  high and low-Medicaid 
discharges  by whether  they  are urban,  rural  or suburban  birthing  hospitals. 
We find very  few significant  differences  between  these variables  on key birthing  hospital 
survey  questions.  However,  in a few areas differences  existed worth  noting  because they 
illustrate  how hospital  implementation  varies  based on location  and type of patients  served. 
If an issue is not represented  in this appendix,  it can be assumed that no differences  were 
found pertaining  to that issue as it concerns  Medicaid  discharge  rates or urbanization. 
Urban,  Suburban,  or Rural  Stabs 
Birthing  hospitals  vary  significantly  regarding  notarization,  especially  on the availability  of 
notaries,  its effect  on the completion  of acknowledgments  and its overall  impact,  based on 
urbanization  (see Table  1).  Intuitively  many  of these differences  could be linked  to a lesser 
demand  for paternity  acknowledgment  services  and/or  a smaller  hospital  staff to do 
notarization  in rural  or suburban  hospitals,  as notaries  are more likely  to be available  only 
during  weekday  business  hours  in rural  and suburban  hospitals  (68 and 64 percent)  compared 
to urban  hospitals  (55 percent).  The availability  of notaries  is less likely  to affect the 
completion  of acknowledgments  in rural  hospitals  (48 percent)  compared  to suburban  or 
urban hospitals  (65 and 63 percent).  Suburban  hospitals  are more likely  to report  a positive 
impact  of notarization  (46 percent)  compared  to both urban  and rural  hospitals  (36 and 32 
percent). 
However,  suburban  hospitals  are less likely  to report  their  relationship  with their  vital 
records  agency  as effective  or very  effective  (72 percent)  contrasted  with urban and rural 
hospitals  (85 and 84 percent).  Rural  hospitals  experience  the greatest  number  of fathers 
visiting  the hospital  (71 percent)  compared  to 68 percent  of suburban  hospitals  and 61 
percent  of urban  hospitals. 
I  Urbanization  status  is based  on  self-reported  information  by  hospital  respondent. 
2  As previously  mentioned,  we sampled  hospitals  based  on whether  they  had  high-Medicaid  discharges 
(over  12 percent)  or low-Medicaid  discharges  (less  than  12 percent). 
B-l  Table  1:  HOSPITAL  DATA  BY URBAN,  SUBURBAN  OR RURAL  STATUS 
Urban  Suburban  Rural 
Notaries  only  available  during  weekday  business  hours  55%  64%  68% 
(45)  (39)  (106) 
Availability  of notaries  affects  completion  of acknowledgments  63%  65%  48% 
(60)  (45)  (79) 
Reported  positive  impact  of notarization  36%  46%  32% 
(33)  (39)  (53) 
Reported  relationship  with  vital  records  agency  85%  72%  84% 
as effective  or very  effective  (109)  (70)  (157) 
All  or most  fathers  estimated  to come  to the hospital  61%  68%  71% 
(75)  (69)  (129) 
Medicaid  Discharge  Rate 
Demographic  factors  comprise  the most notable  differences  between  hospitals  with a high and 
low-Medicaid  discharge  rate  (see Table 2).  High-Medicaid  hospitals  are more likely  to be 
public  hospitals  (68 percent)  compared  to low-Medicaid  hospitals  (60 percent).  In addition, 
39 percent  of high-Medicaid  hospitals  are located  in urban areas compared  to 27 percent  of 
low-Medicaid  hospitals.  Far fewer  (16 vs.  31 percent)  high Medicaid  hospitals  are found in 
suburban  areas compared  to low-Medicaid  hospitals.  However,  little  difference  exists in 
rural  hospitals  based on Medicaid  discharge  status, with 43 percent  of high-Medicaid 
hospitals  located  in rural  areas compared  to 41 percent  of low-Medicaid  hospitals.  The 
greatest  need for offering  acknowledgment  services  exists at high-Medicaid  hospitals  (60 
percent)  contrasted  with low-Medicaid  hospitals  (51 percent).  High-Medicaid  hospitals  are 
also more likely  to conduct  prenatal  education  on paternity  acknowledgment. 
B-2 
 Table  2:  HOSPITAL  DATA  BY MEDICAID  DISCHARGE  STATUS 
Over  12%  Under  12% 
Medicaid  Discharge  Medicaid  Discharge 
Ownership  Type 
Public  Hospital  68%  60% 
(146)  (144) 
Private  Hospital  25%  33% 
(W  (71) 
Urbanization 
Urban  Hospital  39%  27% 
(69)  (62) 
Suburban  Hospital  16%  31% 
(29)  (67) 
Rural  Hospital  43%  41% 
(91)  (96) 
Great  or very  great  need  at hospital  for  60%  51% 
offering  acknowledgment  services  (128)  (133) 
Hospital  conducts  prenatal  education  on  24%  17% 
paternity  acknowledgment  for parents  (32)  (24) 
High-Medicaid,  Urban Hospitals 
Although  very  few hospitals  report  the program  difficult  or very  difficult  to administer,  high-
Medicaid,  urban  hospitals  are more likely  to report  this compared  to other  hospitals  (18 vs. 
11 percent).  See Table  3 for a complete  listing.  This difference  could  reflect  the greater 
need for paternity  acknowledgment  services  in these hospitals  and the additional  challenge 
this creates  in training  staff and allocating  resources  for the program.  Father  participation  is 
also less likely  in high-Medicaid,  urban  hospitals  compared  to other  hospital  types.  Only 52 
of these  hospitals  report  that all or most fathers  come to the hospital  compared  to 70 percent 
of all other  hospitals.  Only  37 percent  of high- Medicaid,  urban  hospitals  report  all or most 
fathers  participate  during  labor and delivery  contrasted  with 48 percent  of fathers  from  other 
hospitals. 
B-3 
 I 
Table  3:  HOSPITAL  DATA  BY HIGH  MEDICAID,  URBAN  STATUS 
High  Medicaid/ 
Urban  Hospital  Other  Hospital 
TYPB 
Find  program  difficult  or very  difficult  to administer  18%  11% 
(13)  (30) 
Father  participation 
All  or most  of fathers  come  to the hospital  52%  70% 
(37)  (236) 
All  or most  of fathers  participate  during  the labor  and  delivery  37%  48% 
(26)  (163) 
Medicaid  Status by Urbanization 
Hospitals  also vary  significantly  based on a combination  of their  Medicaid  discharge  rates 
and urbanization  (see Table 4).  Fifty-three  percent  of high-Medicaid,  rural  hospitals  did not 
consider  themselves  part of a Statewide paternity  acknowledgment  program  contrasted  with 
only  15 percent  of high-Medicaid,  suburban  hospitals. 
High-Medicaid,  suburban  and urban hospitals  are more likely  to actively  promote  the idea of 
paternity  acknowledgment  to parents  as a perceived  role of hospital  staff (63 and 47 percent) 
compared  with low-Medicaid,  urban  hospitals  (26 percent).  The hospitals  most likely  to 
report  all or most fathers  come to the hospital  are low-Medicaid,  rural  hospitals  (82 percent) 
compared  to only  52 percent  of high-Medicaid,  urban  hospitals. 
Table  4:  HOSPITAL  DATA  BY MEDICAID  STATUS  BY URBANIZATION 
High-Medicaid  Hospital  Low-Medicaid  Hospital 
Urban  Suburban  Rural  Urban  Suburban  Rural 
Reported  they  do not  consider  themselves 
 33%  15%  53%  35%  38%  23% 
part  of Statewide  paternity 
 (21)  (4)  (43)  (20)  (24)  (24) 
acknowledgment  program 

Actively  promote  the idea  of paternity 
 47%  63%  30%  26%  37%  39% 
acknowledgment  to parents  as perceived 
 (32)  (17)  (29)  (18)  (27)  (38) 
role  of hospital  staff 

All  or most  of fathers 
 52%  77%  58%  70%  65%  82% 
come  to the hospital 
 (37)  (22)  (54)  (38)  (47)  (75) 
B-4 
 APPENDIX  C 

ESTIMATES  AND  CONFIDENCE  INTERVALS 
The chart below  summarizes  the estimated  proportions  and the 95 percent  confidence 
intervals  for key  statistics presented  in this report.  This  stratified  random  sample required 
using SUDAAN3 to compute  the correct  standard  errors  for the estimates,  based on weighted 
data. 
Table  1:  POINT  ESTIMATES  AND  CONFIDENCE  INTERVALS  FOR  KEY  QUESTIONS.  ] 
95%  Confidence 
Question  Point  Estimate  Interval 
Proportion  of hospitals  viewing  acknowledgment  program  as helpful  or very  helpful  to parents. 
70.0%  65.0%  - 75.0% 
Proportion  of hospitals  rating  acknowledgment  process  as easy  or very  easy  for parents  to understand. 
57.8%  52.7%  - 63.0% 
Proportion  of hospitals  rating  acknowledgment  program  as simple  or very  simple  to administer. 
49.8%  44.7%  - 54.9% 
Proportion  of hospitals  describing  their  relationship  with  the vital  records  agency  in working  together  as 
effective  or very  effective. 
81.2%  77.0%  - 85.4% 
Proportion  of hospitals  reporting  no  barriers  hinder  their  relationship  with  the vital  records  agency. 
75.9%  71.6%  - 80.3% 
Proportion  of hospitals  reporting  no  relationship  exists  with  the child  support  enforcement  agency  in 
administering  acknowledgment  program. 
52.5%  47.1%  - 57.9% 
Proportion  of hospitals  that  do not  consider  themselves  to be part  of Statewide  program. 
34.5%  29.4%  - 39.5% 
Proportion  of hospitals  reporting  an effective  or very  effective  relationship  with  child  support  agency. 
73.0%  66.2%  - 79.8% 
Proportion  of hospitals  currently  paid  or have  been  paid  in the past  for processing  acknowledgments. 
83.6%  78.7%  - 88.5% 
3  SUDAAN  - Release  7.11,  Research  Triangle  Park,  North  Carolina:  Research  Triangle  Institute,  1997. 
C-l  II 
Table  1:  POINT  ESTIMATES  AND  CONFIDENCE  INTERVALS  FOR  KEY  QUESTIONS.  II 
95% Confidence 
Question  Point  Estimate  Interval 
Proportion  of hospitals  fmding  the payment  for processing  acknowledgments  made  a moderate  or great 
difference  in  their  hospitals  ability  to administer  the program. 
76.6%  69.3%  - 83.9% 
Proportion  of hospitals  receiving  staff  training  and  educational  materials  on  the acknowledgment  process. 
71.8%  67.2%  - 76.4% 
Proportion  of hospitals  provided  brochures,  pamphlets,  or handbooks  for staff  training. 
II  I 
57.0%  I  51.9%  - 62.1%  II 
Proportion  of hospitals  attempting  follow-up  contact  with  parents  who  leave  the hospital  without 
acknowledging  paternity. 
18.7%  14.7%  - 22.7% 
II
Proportion  of hospitals  providing  parents  with  training  and  educational  materials  on paternity
acknowledgment.  II 
II  II 
73.8%  69.3%  - 78.4% 
Proportion  of hospitals  using  brochures,  pamphlets,  or handbooks  to tram  parents. 
67.2%  62.4%  - 72.1% 
II
Proportion  of hospitals  using  birth  certificate  worksheets  to fill  out prior  to discussing  birth  registration
and  paternity  acknowledgment  with  a staff  member.  II 
83.9%  79.8%  - 88.0% 
Proportion  of hospitals  reporting  no  internal  barriers  to providing  paternity  acknowledgment  services. 
54.4%  49.2%  - 59.6% 
Proportion  of hospitals  reporting  notarization  has a negative  impact  on  their  acknowledgment  process. 
23.5%  18.3%  - 28.6% 
Proportion  of hospitals  reporting  the availability  of notaries  affects  the completion  of acknowledgments. 
57.4%  51.8%  - 63.0% 
Proportion  of hospitals  reporting  that notaries  are  available  only  during  weekday  business  hours. 
63.5%  58.9%  - 68.2% 
Proportion  of hospitals  reporting  their  role  is to inform  parents  about  the rights  and  responsibilities  that 
accompany  paternity  acknowledgment. 
I  75.5%  I  71.0%  - 80.0% 
c-2  II 
Table  1:  POINT  ESTIMATES  AND  CONFIDENCE  INTERVALS  FOR  KEY  OUESTIONS. 
95%  Confidence 
Question  Point  Estimate  Interval 
Proportion  of hospitals  reporting  the  father  most  often  creates  a barrier  to acknowledging  paternity. 
56.9%  51.0%  - 62.7% 
Proportion  of hospitals  finding  that new  parents  cohabitating  or in a long  relationship  strongly  or very 
strongly  influences  parents  who  voluntarily  acknowledge  paternity  at the hospital. 
81.0%  76.7%  - 85.4% 
Proportion  of hospitals  reporting  that all or most  unmarried  fathers  come  to the hospital  during  the mother 
and  babys  hospital  stay. 
I  67.7%  62.8%  - 72.7% 
Proportion  of hospitals  estimating  that all or most  unmarried  fathers  participate  during  labor  and  delivery. 
45.3%  40.4%  - 50.2% 
Proportion  of hospitals  reporting  that a bad  relationship  between  the new  parents  strongly  or very  strongly 
influences  parents  who  do not  voluntarily  acknowledge  paternity  at the hospital. 
75.2%  69.9%  - 80.5% 
c-3