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 OIG’s 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. 

OEI’s Dallas Regional Office prepared 

Regional Inspector General. 

Project Staff included: 

DALLAS REGION 

Ruth Ann Dorrill, Project Leader 

Michelle Adams, Ph.D 

Karen Erickson, Intern 

Lisa Lesh, Intern 

Marnette Robertson 

Sarah Taylor 

Nancy Watts 

this report under the direction of Chester B. Slaughter, 

HEADQUARTERS 

Ann O’Connor, Program Specialist 

Linda Moscoe 

Barbara Tedesco 

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 mother’s 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 women’s health 

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

not responded one month after the survey’s 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 President’s 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 don’t 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 

Excellent 

Good 

Fair 

Poor or Very Poor 

Ability Effort 

Child Support Vital Records Child Support Vital Records 

8% 8% 8% 8% 

(1) (1) (1) (1) 

77% 67% 67% 67% 

(10) (8) (8) (8) 

15% 17% 17% 25% 

(2) (2) (2) (3) 

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 don’t provide any 

feedback to the hospitals they have assessed. Of the four remaining sample States which 

don’t 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 hadn’t 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 highMedicaid 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 State’s 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 hospital’s job to process birth registration information and therefore can’t 

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 hospital’s 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 didn’t 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 

Brochures/Pamphlets/Handbook 

On-Site Lectures or Seminars 

Video Tape Training 

Other (examples: regional workshops, 

individual meetings, l-800 phone number, etc.) 

Child Support Vital Records Hospitals 

93% 54% 60% 

(14) (7) (242) 

87% 85% 23% 

(13) (11) (106) 

40% 0% 18% 

(6) (0) (57) 

67% 40% 16% 

(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 family’s 

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 

Brochures/Pamphlets/Handbook 

Video Tape Training 

On-site Lectures or Workshops 

Other (examples: regional workshops, 

Child Support Birthing Hospitals 

100% 67% 

(14) (195) 

79% 23% 

(11) (60) 

71% 2% 

(10) (7) 

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 State’s 

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 Doesn’t 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 State’s 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 don’t 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 

Informing Parents of their Rights and Responsibilities 

Helping to Facilitate the Documentation of Acknowledgment 

Actively Urging or Encouraging Parents to Acknowledge 

Child Vital 

support Records Hospitals 

87% 71% 76% 

(13) (10) (317) 

100% 71% 59% 

(15) (10) (24% 

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 Mother’s 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 baby’s 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 

New parents cohabitating or in long relationship 

Emotional feelings with baby’s arrival 

Exposure to idea of paternity from hospital staff 

Exposure to idea of paternity 

from prenatal care providers 

Pressure from paternal grandparents 

Pressure from maternal grandparents 

Child Support Hospitals 

80% 82% 

(12) (258) 

68% 75% 

(10) Gw 

68% 41% 

(10) (161) 

33% 33% 

(5) (63) 

14% 28% 

(2) (56) 

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 mother’s fear of sharing custody, and the short length of her hospital stay (see Table 7). 

The closest agreement between agencies and hospitals is the mother’s fear of violence from 

the father, the father not visiting the hospital, and the mother’s 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 

mother’s hospital stay*‘j, and the mother’s 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 doesn’t 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 baby’s 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 high17 
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 

Bad Relationship Between the Unmarried Parents 

Father Doesn’t Visit the Hospital 

Mother’s Fear of Sharing Custody With the Father 

Length of the Hospital Stay Short 

Lack of Understanding About Paternity Establishment 

Mother’s Fear of Not Receiving AFDC or Other Benefits 

Mother’s Fear of Violence From Father 

Pressure From Maternal Grandparents 

Pressure From Paternal Grandparents 

Child Support Hospitals 

100% 75% 

(15) (253) 

87% 76% 

(13) (246) 

87% 42% 

(13) (128) 

80% 41% 

(12) (131) 

60% 31% 

(9) (104) 

50% 61% 

(7) (180) 

46% 36% 

(6) (74) 

8% 26% 

(1) (56) 

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 couldn’t 

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 hospital’s 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 
10. 

11. 

12. 

13. 

14. 

15. 

16. 

17. 

18. 

19. 

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. 

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. 

At the time of data collection, one sample vital records agency played no role in 

administering its State’s voluntary acknowledgment program. 

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). 

Birthing hospital respondents were given latitude in identifying their child 

support office for our survey. For example, if they used the agency’s 

departmental name such as “Social Services” instead of “Child Support 

Office,” we credited them as having identified the correct office. 

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). 

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. 

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. 

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. 

A number of hospital respondents emphasize the importance of prenatal outreach, 

writing that “Mothers listen to their prenatal care providers,” and “Parents often 

don’t know the dejinition of the word paternity when they come to the hospital.” 

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. 

21. 

22. 

23. 

24. 

25. 

26. 

27. 

The child support agency from one of the 15 sample states did not respond 

when asked about notarization. 

Not all State voluntary paternity acknowledgment affidavits include space for 

separate notary seals for the mother and father’s signatures, although a 

Paternity Affidavit Taskforce formed by OCSE following passage of 

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

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 child’s 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. 

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 child’s 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. . . ” 

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 doesn’t 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. ” 

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. 

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. ” 

Some fathers may not visit during the mother’s 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 SAMF’LE AND NON-SAMPLE STATES 

The fifteen States selected for the hospital-level analysis differed significantly from nonsample 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 hospital’s 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 Hospital’s Ability: 

Excellent 8% 25% 20% 

(1) (7) (f3) 

Rating of Hospital’s 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 

Notaries only available during weekday business hours 

Availability of notaries affects completion of acknowledgments 

Reported positive impact of notarization 

Reported relationship with vital records agency 

as effective or very effective 

All or most fathers estimated to come to the hospital 

Medicaid Discharge Rate 

Urban Suburban Rural 

55% 64% 68% 

(45) (39) (106) 

63% 65% 48% 

(60) (45) (79) 

36% 46% 32% 

(33) (39) (53) 

85% 72% 84% 

(109) (70) (157) 

61% 68% 71% 

(75) (69) (129) 

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 

Ownership Type 

Public Hospital 

Private Hospital 

Urbanization 

Urban Hospital 

Suburban Hospital 

Rural Hospital 

Great or very great need at hospital for 

offering acknowledgment services 

Hospital conducts prenatal education on 

paternity acknowledgment for parents 

High-Medicaid, Urban Hospitals 

Over 12% Under 12% 

Medicaid Discharge Medicaid Discharge 

68% 60% 

(146) (144) 

25% 33% 

(W (71) 

39% 27% 

(69) (62) 

16% 31% 

(29) (67) 

43% 41% 

(91) (96) 

60% 51% 

(128) (133) 

24% 17% 

(32) (24) 

Although very few hospitals report the program difficult or very difficult to administer, highMedicaid, 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 

Reported they do not consider themselves 

part of Statewide paternity 

acknowledgment program 

Actively promote the idea of paternity 

acknowledgment to parents as perceived 

role of hospital staff 

All or most of fathers 

come to the hospital 

BY MEDICAID STATUS BY URBANIZATION 

High-Medicaid Hospital Low-Medicaid Hospital 

Urban Suburban Rural Urban Suburban Rural 

33% 15% 53% 35% 38% 23% 

(21) (4) (43) (20) (24) (24) 

47% 63% 30% 26% 37% 39% 

(32) (17) (29) (18) (27) (38) 

52% 77% 58% 70% 65% 82% 

(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 hospital’s 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% 

Proportion of hospitals providing parents with training and educational materials on paternity IIacknowledgment. II 

II 73.8% 69.3% - 78.4% II 

Proportion of hospitals using brochures, pamphlets, or handbooks to tram parents. 

67.2% 62.4% - 72.1% 

Proportion of hospitals using birth certificate worksheets to fill out prior to discussing birth registration IIand 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 baby’s 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