On the Front Lines of Paternity Establishment: Perspectives of Parents and Birth Registrars

CFRP Policy Brief | B.014.1214

December 2014

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Because children of unmarried parents do not have a legal father until paternity is established, federal and state laws mandate provision of readily accessible means of establishing paternity. In Texas, each hospital provides an Acknowledgment of Paternity (AOP) form for parents to sign as part of the birth registration process. Although most parents choose to establish paternity this way, few studies have examined the AOP process to determine whether it is working optimally for parents, children, and hospitals. To investigate this issue, the Child and Family Research Partnership (CFRP) collected data from Texas mothers who had given birth outside of marriage, birth registrars who admister the AOP process, and Paternity Outreach Coordinators (POCs) who oversee paternity establishment operations across the state. Results suggest that birth registrars are largely successful in guiding parents through the AOP process, but they are often unprepared for addressing challenges related to sensitive or complex issues such as family violence, genetic testing, and third-party AOPs. Clearer policies and training to address these issues may help hospitals manage the process more effectively, improve its accuracy, and provide birth registrars with the tools they need to enhance parents’ experiences and ensure the best outcomes for children.

Little is known about the perspectives of the parents who undergo the paternity establishment process or the personnel who administer it.

More than two in five children in the United States are born to unmarried parents. Because these children do not have a legal father until paternity is established, a number of laws and regulatory changes have been put in place to simplify and promote the paternity establishment process. As a result, most unmarried parents in Texas establish paternity voluntarily by signing an Acknowledgment of Paternity (AOP) form in the hospital as part of the birth registration process after their child is born. However, few studies have examined this process in detail to determine whether it is working as intended. Moreover, little is known about the perspectives of the parents who undergo the AOP process and the hospital personnel who administer it.

To investigate this issue, CFRP collected data through two separate surveys: one of 800 Texas mothers who had recently given birth outside of marriage, and another of 555 hospital staff certified to guide parents through the AOP process in Texas. Additionally, CFRP conducted a roundtable discussion with staff from the Texas Child Support Division who oversee the in-hospital paternity establishment program across the state. Together, these perspectives helped CFRP form a broad overview of the AOP process.

Nearly nine in ten unmarried couples sign the AOP form when both parents are at the hospital.

The findings show that birth registrars are largely effective in executing in-hospital paternity establishment. Under their guidance, nearly 9 in 10 unmarried couples sign the AOP form when both parents are present for the birth. Nonetheless, birth registrars are not always able to address parents’ needs, particularly with regard to complex legal issues that commonly arise. Moreover, they are often unprepared for highly sensitive or contentious circumstances, such as cases of family violence, when it may be preferable that a father establish paternity through alternate means altogether. These findings point to the need for a more nuanced perspective on the objectives of paternity establishment, and for clearer and more uniform policies, training, and tools to address the foreseeable challenges that birth registrars face.

AOP-Certified Staff Have a Wide Range of Experience

Many types of hospital staff can be certified to administer the AOP process. For most of these professionals—such as nurses, health information managers, social workers, and midwives—birth registration (during which the AOP is administered for unmarried parents) is just one responsibility among many. Due to the varied responsibilities of this group, only half report having administered an AOP in the previous week, and 3 in 10 have not done so for a month or more. By contrast, staff who perform birth registration as their primary responsibility complete AOPs on a far more regular basis: 94 percent report overseeing at least one AOP in the previous week. As a result, this smaller group completes the majority of AOP forms and accumulates more experience with the process. Nonetheless, this group earns lower average hourly wages ($14.31) than other AOP-certified staff ($15.31). To capture the full range of experiences among personnel who administer the AOP, the remainder of this brief presents findings that reflect the combined perspectives of all types of AOP-certified staff.

High Stress & Frequent Turnover Trigger Treadmill of Training

Almost a quarter of birth registrars have been AOP-certified for a year or less, while 21 percent have been certified for 10 years or more [Figure 1]. This bimodal distribution, and in particular the high proportion of new staff, is suggestive of ongoing challenges with high turnover. According to Paternity Outreach Coordinators (POCs), the face-to-face assistance, monitoring, and evaluation demanded by a steady stream of new trainees diverts time and resources from other aspects of the AOP program. High turnover may also compromise parents’ full understanding of paternity establishment and its implications. At any given time, a considerable number of registrars have had little practice with what can be a complex and emotional legal process.



Paternity Outreach Coordinators attribute high turnover partly to high stress, low wages, and lack of support from hospital management. One area of friction between hospital management and staff may stem from the fact that 8 in 10 hospitals use customer service goals to evaluate birth registrars. This approach can favor conflict avoidance over the sensitive and sometimes contentious task of ensuring that parents fully understand what they are signing. This dilemma—which can pit birth registrars’ AOP responsibilities against their obligations toward the hospital—may reflect conflicting priorities hospitals themselves must manage, since they are legally required to administer the AOP but receive no funding to do so.

Hospitals’ customer-service orientation may be at odds with the sensitive nature of the AOP process.

Obstacles to In-Hospital Paternity Establishment

Paternity establishment lengthens an already time-consuming birth registration process. Among birth registrars, 98 percent agree that registration for unmarried parents requires more work, and 42 percent say it is “much more work.” Nearly two-thirds report that the AOP adds an average of 15 to 30 minutes to the process. Complex situations lengthen it further: 3 in 10 say the AOP adds more than an hour. The following section describes the issues that most often complicate or even derail the AOP process.

Most Common Issues

Father Unavailability

Father absence is the most common reason parents do not sign the AOP.

Among both parents and registrars, father absence is the reason most cited for failure to sign the AOP. Notably, 23 percent of unmarried fathers are not present at the birth when the opportunity to establish paternity is offered. These birth-absent fathers make up more than two-thirds of those who do not establish paternity in the hospital. Roughly one-quarter of birth registrars point to schedule mismatch with fathers as part of the problem. Relatively few registrars are on site evenings and weekends, when working fathers are most likely to be available. Among non-signing parents, 17 percent indicate that they were not given the chance to sign. This finding may reflect a potential oversight related to partial AOPs: when a father is absent, the mother should still be provided the opportunity to complete her portion of the AOP. However, POCs believe some registrars may be confused on this point and fail to offer the AOP when the father is not present.

Third-Party AOP

When fathers are absent from the hospital, mothers should still have the chance to complete a partial AOP.

When a mother has a child with someone other than her husband (or recent ex-husband), the husband (or ex-husband) must deny paternity before the biological father can establish paternity. This situation can prompt arguments among family members, or between parents and staff, and the complex legal nature of the situation further compounds the difficulties for registrars. POCs who have sought guidance on such matters from decentralized regional oversight staff report receiving inconsistent or contradictory advice.

Lack of Proper Identification

Staff note that fathers sometimes fail to provide appropriate ID. Given the many acceptable forms, including documents such as a current utility or cell phone bill, it’s unclear whether this problem can be attributed solely to fathers. It is possible that some birth registrars themselves are unaware of the full range of legally acceptable forms of ID.

Misunderstanding the AOP

When asked to identify other complicating factors that commonly arise during the AOP process, 5 percent to 10 percent of birth registrars point to the following issues, many of which overlap:

  • Language barriers
  • Illiteracy
  • Confusion among parents about issues related to child support
  • Trouble understanding the AOP among young parents and minors

Some parents think the father will automatically have to pay child support after signing the AOP.

Together, these examples reflect a general problem: Many parents have trouble fully understanding the AOP process. One common source of this problem is the complex legal language found in the AOP. Birth registrars report that specific sections of the document routinely pose challenges for parents. Table 1 summarizes those sections and common points of confusion.

Table 1: Sections of AOP Form That Parents Have the Most Difficulty Understanding

Section Points of Confusion

Benefits, Rights, Responsibilities

Issues related to child support: How/if a child support case will be opened; some parents think father will automatically have to pay child support after signing

Denial of Paternity

Denial process and definition of “presumed father”

Genetic Testing

Issues related to DNA testing; some parents mistakenly think they are signing a form to get a DNA test or will be required to get a DNA test

Change of Mind

Process of rescission and related phrases, including “Rescission of Acknowledgment of Paternity” and “fraud, duress, or material mistake of fact”

Source: NBAR study

Doubts About Paternity

When asked why they did not sign the AOP, more than a quarter of mothers reported that either they or the assumed father were not sure of the child’s true paternity. Birth registrars are even more likely to recognize this as an issue—64 percent believe that doubts about paternity explain parents’ decision not to sign.

Nearly half of birth registrars don’t feel “very prepared” to address concerns about DNA testing.

This issue warrants concern given that half of birth registrars do not feel “very prepared” to answer questions or address concerns about DNA testing. This lack of preparation may contribute to parents’ confusion about the AOP process. Relative to parents who sign the AOP, those who do not are significantly less likely to agree that the registrar informed them of their ability to request a DNA test before establishing paternity. They are also less likely to say that the registrar was able to answer questions about signing the AOP or establishing paternity.  As seen in Table 1, some parents mistakenly think they are signing a form to get a DNA test or will be required to take one. This finding is particularly important because incorrect or mistaken paternity establishment by a non-biological father can be especially difficult to reverse once 60 days have passed.

Violence: Misperceptions, Missed Training Opportunities

When family violence is present, the preferred arena for paternity establishment is not the hospital but the court system, where safe parameters for visitation and child support can be established. The birth registration process provides a crucial opportunity for diverting victims of violence to this alternate means of establishing paternity. Despite the importance of this intervention point, detection is especially difficult during the brief meeting between parents and registrars. As a result, it is perhaps unsurprising that birth registrars underestimate the prevalence of violence among unmarried parents.

  • Roughly 20 percent of surveyed mothers have experienced family violence since becoming pregnant.
  • More than 9 in 10 birth registrars estimate the rate of family violence to be 10 percent or less among the parents they work with.
  • Among fathers absent from the birth, 43 percent are abusive.
  • Among fathers who attend the birth, 13 percent are abusive—of these, 86 percent sign the AOP in the hospital.
  • Only 3 percent of registrars report ever having stopped the AOP process due to concerns about violence.

Birth registrars greatly underestimate the prevalence of violence among the parents they serve.

AOP training does not include guidance on detection of violence, although some POCs report addressing the topic in face-to-face trainings. Hospitals do typically provide policies addressing on-site violence, but they are much less likely to provide direction on the subtler task of identifying signs that it may be occurring elsewhere. More than half of birth registrars report that their hospitals have a policy in place for addressing cases of suspected family violence, but those policies are often vague and inconsistent. Moreover, they are not specific to the AOP process.

Policy Implications

Overall, the results indicate that birth registrars are trained in accordance with state directives, knowledgeable about the parents they serve, and effective in their execution of the AOP process. Nonetheless, the findings demonstrate the need for minor but important adjustments to the policies, administrative practices, training, and materials that provide guidance for registrars and parents. 

Comprehension of the AOP Process

Parents typically first learn about paternity establishment when they arrive at the hospital for the delivery of their child. Earlier outreach during pregnancy and improved educational materials (e.g., with adjustments that more explicitly distinguish between paternity acknowledgment, child support, and genetic testing) may improve parents’ comprehension of the paternity establishment process, the legal language in the AOP, and the implications of signing or not signing this important document. Earlier outreach may also expand signing opportunities for fathers who cannot attend the delivery. Additionally, improved methods of confirming parents’ understanding of the AOP may help ensure accurate comprehension. 

Genetic Testing

Training should prepare registrars to provide information proactively on DNA testing services when paternity is in doubt. The Office of the Attorney General (OAG) might also consider expanding availability of free DNA testing—currently provided only to parents applying for child support—to all unmarried parents seeking confirmation of paternity. 

Family Violence

Clear and uniform policies and training should prepare birth registrars for detecting family violence and for taking steps to intervene or redirect the AOP process when necessary. Policymakers might also consider addressing family violence within state law regulating paternity establishment. The Texas Family Code, which requires birth registrars to offer the AOP to unmarried parents, might benefit from a provision that recognizes suspicion or evidence of family violence as an exception to the standard AOP process. 

Third Party AOPs

The OAG should consider re-evaluating the policy requiring third-party AOPs in cases in which a mother is having a child with someone other than her husband or recent ex-husband. The policy purpose for this stipulation is unclear, particularly given that no similar condition is placed on married fathers wishing to establish extramarital paternity without the permission of their wives. Elimination of the requirement – in other words, simply allowing a two-party AOP as in all other cases of paternity establishment – would prevent a significant amount of confusion and stress for birth registrars and parents. 


Centralization of the Paternity Opportunity Program may improve interregional collaboration and consistency, particularly when POCs and registrars seek counsel for complicated issues. The OAG might also consider exploring ways to align hospital incentives with AOP goals and appropriating funds to incentivize continued high AOP performance. Hospital management should also consider making adjustments to staff performance measures that hold birth registrars to conflicting standards.

Together, these adjustments may help strengthen the support system for hospitals and birth registrars as they oversee the sensitive and often complex AOP process, and in turn improve unmarried parents’ ability to make fully informed decisions about paternity establishment.