In-Hospital Paternity Establishment: A Study of Staff, Parents, and Policy

CFRP Report | R.006.0714

July 2014  

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The Texas Office of the Attorney General, Child Support Division (OAG) contracted with the Child and Family Research Partnership (CFRP) to provide recommendations regarding ways to expand paternity education, increase or sustain federal performance of paternity measures, and reduce the incidence of rescissions of paternity establishment. To inform recommendations to the OAG, CFRP developed a research program to determine the prenatal, environmental, and parental factors that affect in-hospital paternity establishment and ascertain when unmarried parents are most receptive to messages about paternity, among other research aims.

The primary goal of this report is to explain the context of the in-hospital paternity establishment process from the perspective of the staff who are certified to administer the Acknowledgement of Paternity (AOP) forms to unmarried parents. Specifically, CFRP examined the demographic characteristics of the AOP-certified staff (AOPCS); their level of experience and training; the support and challenges they face in their jobs; and their interactions with the families they serve.

To inform the research aims noted above, CFRP developed the Nonmarital Birth and Registration (NBAR) study, an online survey of AOP-certified staff across Texas conducted in January of 2014. Topics covered in the NBAR survey include demographic characteristics of AOP-certified staff, workload, support from hospital staff and management, and views about parents and the AOP process. In addition, this report draws on information gathered from roundtable discussions and interviews with paternity outreach coordinators, as well as data from the Paternity Establishment Study (PES), a previous CFRP study of over 800 unmarried mothers in Texas.

Drawing on analyses of survey data, focus groups, and interviews, this report provides recommendations that aim to improve the AOP process in Texas. These recommendations are designed to generate higher and more accurate levels of paternity establishment among unmarried fathers, fewer paternity disestablishments, and improved compliance with child support obligations.


Between 1980 and 2012, the proportion of nonmarital births in the United States doubled. Today, approximately two out of five U.S. births are to unmarried mothers. This dramatic rise in the number of nonmarital births is of growing concern because of the precarious economic status of single parents (most often mothers) and their children. Moreover, there is a host of negative social, emotional, and behavioral outcomes associated with children who live in poor, single-parent families—especially when those families lack involved and supportive fathers.

One strategy to promote a father’s financial and emotional investment in his child is to encourage the establishment of paternity. Paternity establishment legally formalizes a father’s rights and responsibilities to his child and is completed by most unmarried parents in the hospital at the time of the child’s birth. Research shows that fathers who voluntarily establish paternity in the hospital are more likely to be involved and supportive of their children in the future, both of which are associated with improved child outcomes. In Texas, roughly 7 in 10 fathers voluntarily establish paternity in the hospital by signing an Acknowledgement of Paternity (AOP) form. The rate of in-hospital paternity establishment, however, is much higher among fathers who are present at the birth; CFRP survey data show that more than 9 in 10 fathers who are present at the hospital sign the in-hospital AOP.

As the proportion of nonmarital births in Texas continues to rise, understanding the process of voluntary paternity establishment becomes increasingly important. Although previous research has examined the motivations and characteristics of parents in this process, this report focuses on the professionals who administer paternity establishment in the hospital. These birth registrars and hospital staff occupy the front lines of paternity establishment and may play a crucial role in parents’ decisions about AOP-signing.

Key Findings

This report organizes its key findings into four broad categories that help to facilitate an understanding of the various dynamics affecting AOP-certified staff (AOPCS): (1) demographic and occupational characteristics, (2) the level of preparation and training of AOPCS, (3) how AOPCS are supported in their work with unmarried parents, and (4) the relationship between AOPCS and parents. Broad findings in each of these areas are discussed below:

Occupational Characteristics

  • Although all staff members who register births are required to be AOP-certified, not all staff members who register births are birth registrars.
  • Birth registrars’ primary job duties entail leading parents through the AOP process; AOPcertified staff members who are not birth registrars generally do not participate regularly in the AOP or birth registration process.
  • Though nearly all birth registrars (94 percent) had helped parents to complete an AOP in the last week, only half of non-registrar AOPCS had done the same.

Demographic Characteristics

  • The vast majority of AOPCS are female and White or Hispanic.
  • Compared to non-registrar AOPCS, birth registrars are more likely to be Hispanic, less likely to have completed a college degree, and more likely to be fluent in another language (usually Spanish).
  • The average reported hourly wage for AOPCS is $15.34, with reported wages ranging from $8 to $40 per hour.
  • On average, birth registrar wages are both lower and less varied than non-registrar AOPCS.

Levels of Preparation and Experience

  • AOPCS are generally well-trained and successfully complete AOPs for 90 percent of couples when the father is present.
  • Many AOPCS are new to the job or have little experience administering the AOP.
  • The most significant gaps in preparation stem from the absence of formal training or policy directives regarding family violence and cases of disputed paternity.
  • A steady crop of new hires often translates into reduced effectiveness and higher levels of on-the-job training and oversight from OAG staff.
  • High turnover among AOPCS is likely the product of several factors including low wages, high stress, and lack of support or understanding from facility management. 

Experience with the AOP Process

  • Most common complications are due to third-party births, father availability, and lack of identification.
  • Parents have difficulty understanding the AOP process, including the legal language in several sections of the AOP form; specific areas of confusion include: (1) opening a child support case, (2) the denial of paternity section, (3) rescission, and (4) genetic testing.

Levels of Support

  • Approximately 83 percent of survey respondents reported working closely with the nursing staff at their facility, and nearly every respondent indicated that the nursing staff was important to their job duties.
  • Furthermore, three-quarters of respondents agreed that the nursing staff generally made their jobs easier.
  • Survey comments also indicate that nursing staff act as helpful points of contact for more complex issues such as family violence.

Understanding of Parents

  • AOPCS generally show a strong grasp of the reasons unmarried parents choose to sign or not sign the AOP.
  • AOPCS are more likely to believe that parents sign the AOP for financial reasons than parents report themselves. Parents and AOPCS also diverged on questions related to the AOP process itself, with parents more likely to report that they had not been given the opportunity to sign an AOP.
  • Schedule mismatch between birth registrars and fathers makes up a small but significant reason that fathers do not sign in the hospital.
  • AOPCS recognize doubts about paternity as a common problem, and note that a significant proportion of fathers inquire about DNA testing.
  • AOPCS commonly indicated that cultural and language barriers make understanding the AOP more difficult for parents.
  • AOPCS tend to underestimate the prevalence of family violence among parents they serve. 

Policy Considerations

Informed by findings from both the NBAR and PES studies, this report highlights policy considerations relevant to OAG practices and training. In general, results from this study indicate AOPCS are knowledgeable about their jobs and receive training in accordance with OAG directives. Nevertheless, survey data also illustrate the need for several minor, but important, adjustments to training, materials, and relationships with facilities. These recommendations are organized into three broad categories based on the policy channels for implementation: 1) improving the OAG administration of the AOP process, 2) improving relationships between the OAG and hospitals, and 3) public policy and legislative considerations. Specifically, results from this study suggest policymakers should:

OAG Administration

  • Improve consistency and collaboration across regions through increased centralization of the Paternity Opportunity Program.
  • Create clear and uniform policies regarding family violence.
  • Improve AOPCS’ abilities to confirm that parents understand the AOP.
  • Ensure that AOPCS proactively provide information on DNA testing services when paternity is in doubt.
  • Make materials available that clearly separate AOP signing and child support.
  • Provide cultural competency training to reduce complications from culture and language differences.
  • Focus efforts to improve third-party AOPs.

Relationships between the OAG and Hospitals

  • Increase the availability of paternity information to expectant parents.
  • Find ways to align hospital incentives with AOP goals.
  • Legislative Considerations
  • Incorporate consideration of family violence issues into law regulating the AOP.
  • Reevaluate the policy consideration for requiring third-party AOPs.
  • Consider appropriating funds to incentivize continued high AOP performance by hospitals.


By its very nature, the AOP process can be a sensitive and complex situation for many unmarried parents. Results from this study make clear that, in general, the staff who administer this process are generally succeeding. Despite a number of challenges inherent to the job, CFRP data show that AOPCS, in combination with Paternity Opportunity Coordinators, AOP-certified entities, and the OAG, have secured high rates of in-hospital paternity establishment across the state. Indeed, when the father is present at the birth, paternity is established nearly 90 percent In Hospital Paternity Establishment: A Study of Staff, Parents & Policy Page 10 of 221 of the time. Still, a number of challenges remain. In particular, room for improvement persists in the legislative domain, as well as in the areas of staff training, relationships with hospitals, and the materials made available to parents. In addition, the OAG should consider centralizing some aspects of the Paternity Opportunity Program in order to improve consistency and collaboration across regions; relatedly, soliciting and responding to feedback from Paternity Outreach Coordinators (POCs) would likely enhance the efficacy of the program, given their strong understanding of the day-to-day realities faced by AOPCS. Adjustments in these policies and procedures may lead to a paternity establishment process that is both higher-quality and more accurate, resulting in greater parent satisfaction and fewer rescissions. 

Click here to read the full report.