The Child Support Improvement Project: Paternity Establishment, Chapter 2

The Child Support Improvement Project: Paternity Establishment, Chapter 2

CHAPTER II

LEGAL, PROCEDURAL AND ADMINISTRATIVE CONSIDERATIONS
IN IMPLEMENTING IN-HOSPITAL PATERNITY
ACKNOWLEDGEMENT EFFORTS

The Colorado Paternity Demonstration Project involved implementing in-hospital voluntary paternity acknowledgement procedures at four hospitals in the Denver area. These facilities are University, Denver General, Saint Joseph, and Mercy Hospitals.
At each facility, arrangements were developed to routinely inform unmarried parents about paternity and offer them the opportunity to voluntarily acknowledge prior to or immediately following their discharge from the hospital. In addition, the Department of Social Services (DSS) assumed payment of all fees associated with the establishment process and handled the paper work that had previously fallen to parents to do.
Implementing hospital-based efforts to encourage unmarried parents to acknowledge paternity has required many accommodations. It has been necessary to simplify the process by which the paternity affidavit may be completed and filed with the Bureau of Vital Statistics (BVS). It has been necessary to gain admittance to hospitals and negotiate the terms and conditions under which patients may be approached. In the course of these negotiations, it has been necessary to address a variety of concerns that hospital administrators, medical personnel, social workers and birth certificate clerks have about paternity establishment programs and their placement in the hospital setting.
The following describes some of the lessons we have gleaned through the process of implementing in-hospital paternity programs in four different settings.

A. Administrative Authority and Procedure

Perhaps the key lesson to be learned from Colorado's experience is the importance of a streamlined and simplified paternity acknowledgement procedure. When the project began, the establishment process in Colorado was cumbersome, time consuming, expensive and extremely discouraging even to interested, unmarried parents. Although a voluntary acknowledgement process existed that provided for paternity to be established on a presumptive basis, there was no effort to explain the benefits of paternity to unmarried parents or to make the option available. More to the point, the Colorado Bureau of Vital Statistics (BVS) did not permit the father's name to be added to the birth certificate at the time of birth even if he was willing to sign the affidavit. Rather, the procedure was for the certificate to be completed without the father's name and submitted to the state for entry on its database. Approximately 15-20 days later, when the registered birth certificate was returned to the mother, the father could obtain a Statement of Paternity from BVS. The father's name was added only if the Statement of Paternity included notarized signatures for both parents and a fee of $27 was sent to BVS. This included a $15 fee to process the change and a $12 fee for a certified copy of the new birth certificate. The new birth certificate with the father's name was usually not available until three to four months following the birth of the baby. Women who had been previously married faced additional hurdles. They were required to produce a certified copy of their divorce decree before the father of the child could be added to the birth certificate using the above noted procedure.
Not surprisingly, paternity establishment rates were low in Colorado hospitals and the process took a very long time. In 1991, a year that clearly preceded the introduction of the project, voluntary acknowledgements at Denver General stood at only 13 percent. At University Hospital, paternity was voluntarily acknowledged in 22 percent of the unmarried births. At Mercy and St. Joseph Hospitals, percentages of voluntary acknowledgements were 24 and 20 percent, respectively.
Following commencement of the project, the fee and time requirements for voluntary paternity acknowledgements posed by BVS were examined and amended. At first, procedural modifications were made only in selected hospitals participating in the project. Subsequently, the changes were adopted state-wide as a result of the enactment of new legislation.
Under state law adopted in 1993 (HB 93-1227), all hospitals are required to make the voluntary acknowledgement process available to unmarried parents at the time of birth. Interested parents have the option of signing a notarized paternity affidavit at birth and having the father's name placed on the birth certificate. If the affidavit is signed within ten days of the baby's birth, there is no fee to the parent associated with the entry. These procedures cover previously married women as long as they were not married either at the time of conception or birth. Finally, for women who were married at these times, the husband and the father of the child may execute notarized documents permitting the father's name to be entered on the birth certificate rather than the husband's (see Appendix A).
Effective July 1994, the process was made even more accessible to unmarried parents when the requirement for notarized signatures was replaced with witnessed ones (see Appendix B). It was hoped that this change would address the problem of a lack of notary publics in hospital settings.

B. Relationships With the Bureau of Vital Statistics

While new laws and simplified administrative procedures are necessary elements of an enhanced paternity acknowledgement process, they are not sufficient. A second key ingredient to a successful voluntary acknowledgement process is coordination between the Child Support Enforcement Division and the Bureau of Vital Statistics. Coordination is needed to ensure that: unmarried parents are routinely approached in hospital settings; birth registration clerks receive training in the voluntary acknowledgement process; hospital-specific performance patterns with respect to paternity can be systematically monitored; and birth certificates can be readily screened by child support workers to determine whether paternity has been voluntarily acknowledged.
The Colorado Paternity Project stimulated many joint discussions between BVS and the child support enforcement unit of the Denver Department of Social Services (DDSS). One outcome of these meetings was the joint production of the Handbook for Hospital-Based Paternity Acknowledgement. In addition to describing the new procedure and presenting all relevant forms, the Handbook identified IV-D contact persons in each county who will serve as liaisons to the hospitals.
Another area of mutual interest is staff training. Following the passage of state law requiring hospitals to make the paternity affidavit available to parents, project staff initiated a state-wide training effort aimed at exposing birth registration clerks and other relevant hospital workers to the paternity issue and the new law. Although this training has been well received, it has demonstrated a need for more sustained training attention. Personnel turnover in hospital settings is high. In order to ensure that new birth registration clerks, nursing staff and discharge planners are aware of the benefits of paternity and the voluntary acknowledgement process, presentations about paternity must be incorporated in the regular training accorded to these types of workers.
Still another outcome of the joint meetings between BVS and DDSS inspired by the project was the development of quarterly data downloads from BVS showing voluntary acknowledgement patterns by hospital facilities. With this performance-based information, project personnel are better able to monitor voluntary acknowledgements at the hospital level and target facilities in need of training and technical assistance.
A recognized, needed area of collaboration between BVS and the state child support agency, which was not accomplished by the conclusion of the project, was the development of an automated interface between the two agencies. The goal of the interface would be to permit child support workers to screen birth certificates on terminals at their own agency for the purpose of identifying whether a father's name is on the birth certificate and whether a child support case requires that paternity be established. Currently, child support workers must request a copy of the birth certificate in order to check whether a father has acknowledged paternity. With an automated link, this information would be available instantaneously during a relevant intake procedure.

C. Access to Hospitals

Another key ingredient to the voluntary acknowledgement process is gaining admittance to hospitals in order to meet with pregnant and newly delivered unmarried mothers and their partners. While there has been no single pattern to the reaction of administrators and staff in the four hospital settings in which the Colorado pilot has been implemented, a number of issues have been raised in one or more of these settings that may be relevant to program replications. These patterns are discussed below.

Human Subject Review Boards

Because our project was initiated prior to the passage of state-wide legislation, and because it had an evaluation component, three of the four Denver area hospitals in which project interventions occurred required project evaluators to prepare extensive written proposals outlining project procedures and anticipated risks to patients and submit them for review by the respective governing Institutional Review Board. Although all the submitted proposals were ultimately approved, the Human Subject Review Board process was lengthy and time consuming. The Boards were interested in learning about all aspects of the project, including the collection and use of any evaluative information. Indeed, one Board contemplated the requirement that project staff obtain a signed, informed consent form from unmarried parents prior to presenting information about paternity. Fortunately, the plan was abandoned when it was noted that the consent form would be more invasive than the paternity acknowledgement process itself. Reviews by Human Subject Review Boards appear to be unnecessary once a state law requiring in-hospital paternity is enacted. However, Board approval is often necessary if any patient-specific information on the impact of in-hospital efforts is to be collected, even after the enactment of a law requiring in-hospital outreach.

Hospital Image

Hospital image factors have also come into play. For example, one hospital which had permitted project staff to make prenatal overtures to unmarried mothers in clinic waiting rooms, decided to discontinue its clinic format and move to an individual appointment system. Moreover, when pregnant women were seen in a group for instruction on nutrition and other issues of pregnancy, the hospital did not want to offend married women by discussing the paternity issue. As a result, it became impossible for staff to make the overture prenatally.

Restrictions on Patient Contact

Three of the four project hospitals granted child support staff access to patients to conduct the paternity interventions. From the start of the project, they placed no restrictions on the use of non-hospital personnel in prenatal or postpartum settings. In one of the four hospitals, however, outsiders were prohibited from making contact with patients for the first year of the project.
After lengthy negotiations at this hospital, the child support agency (DDSS) agreed to fund an entry level social work position and the hospital agreed to hire a social worker for the exclusive purpose of conducting paternity orientations. The arrangement lasted for about a year. During this time, this worker was jointly supervised by DDSS and the hospital's social work department. There were several limitations to this arrangement. One was the inability to provide back-up for the social worker during weekends and personal leave days. Another limitation of this arrangement was the requirement to comply with the hospital social work department's time-consuming procedures for documenting patient contacts. After a year of experimentation, evaluation and negotiation, the hospital relented and agreed to allow DDSS personnel to make the paternity presentations to unmarried parents.

D. Personnel to Make the Paternity Overture

There were several considerations to take into account in determining who should make the paternity overture in hospital settings. Scheduling considerations were critical. It was necessary to provide coverage throughout the week, including weekends, holidays and personal leave days. Until the requirement for notarization was dropped, it was also important to have personnel available at the hospitals who could notarize the fathers' signatures during evening and other non-traditional work hours. In addition, since successful paternity interventions are positive and energetic, it was necessary to identify motivated and committed personnel in every hospital setting. A final consideration had to do with workload concerns. Hospital workers, like birth registration clerks, may object to the prospect of being asked to assume a new responsibility without any increase in staff support or remuneration. Not surprisingly, there are definite pluses and minuses to using different types of personnel to make paternity overtures.

Child Support Workers

We relied on child support workers to staff the in-hospital paternity effort in most of the participating hospitals in this project. There were several reasons for this staffing decision. The project began before there was a state-wide law requiring hospitals to present the paternity option to unmarried parents. There was some question as to whether birth registration clerks would assume this duty without a legal requirement to do so.
Another reason in favor of using DDSS workers was the proximate location of several hospitals with large numbers of out-of-wedlock births. This made it feasible for a DDSS worker to visit several hospitals on a daily basis to meet with unwed mothers and fathers following delivery. Moreover, since DDSS workers share the agency's desire to improve its Paternity Establishment Percentage, they proved to be highly motivated and effective presenters. Another strength that DDSS workers brought to the job is working knowledge of the child support and benefit systems. They were able to handle the questions that parents had about these issues. When notarization was necessary, it was easy to make child support workers notary publics. Consequently, they were able to complete the paternity affidavit with its requirement for notarized signatures for each parent. Finally, DDSS workers willingly accommodated the client documentation and data collection requirements of the project evaluation.
The chief drawback to this arrangement obviously is its cost. While it is not overly time consuming for a DDSS worker in Denver to visit several high volume hospitals on a daily basis, this might be impractical in rural settings and in urban settings with more traffic congestion. Another limitation is the lack of evening coverage. While DDSS workers may effectively reach all mothers in the course of a daily visit, they cannot catch all unmarried fathers. Thus, the use of DDSS personnel does not eliminate the need to have hospital personnel, who are notaries (when notarization is necessary), available to accommodate unmarried fathers whenever they show up to visit, including evenings when the DDSS worker is not on the scene. A final drawback to using DDSS workers is their affiliation with the child support and welfare programs. To maximize their acceptance by unmarried parents, workers have found it helpful to dissociate themselves from the agency and present themselves as paternity "workers."
Over time, birth registration clerks at each of the project hospitals assumed the paternity orientation function and DDSS workers were phased out of the process in Denver. The project DDSS worker succeeded in training each hospital's birth registration clerk to assume a more aggressive role in paternity establishment. Given the turnover in birth registration clerks and other labor and delivery personnel in hospital settings, however, it will be necessary to develop a mechanism for continual training of new workers in the paternity acknowledgement process.

Social Workers

Moving beyond scheduling and work-load considerations, we have found that different hospital staff evoke reactions in unmarried parents that can be either helpful or harmful to the paternity overture. For example, in the one hospital setting where the overture was made by a hospital social worker, it was helpful to minimize the connection between the paternity orientation and the social work function. Due to their work in the child protection arena and the increasing number of child placements that occur as a result of the rising use of drugs among pregnant and newly delivering mothers in inner cities, social workers are often feared and mistrusted by unmarried mothers at delivery. The project social worker found it helpful to merely introduce herself as a paternity worker and to de-emphasize her affiliation with the hospital's social work department.

Nurses

Nursing staff have access to unmarried mothers and are generally trusted. On the other hand, they are typically uninformed about the paternity issue and/or too busy to address this issue along with everything else they do. With hospital training efforts, it might be possible to convince staff to incorporate paternity with other parent education functions they perform. For example, in one hospital, nurses conduct a daily discharge class where the paternity issue might logically be addressed. Unfortunately, the private views of presenting personnel may come into play. In this hospital, one nurse handling the class was opposed to paternal involvement and urged mothers not to sign the affidavit. As a result of project intervention, negative instructions were discontinued; however, they were not replaced with a positive message.

Birth Registration Clerks

Birth registration clerks are clearly the most logical workers to make the paternity overture. However, they too face pressures that conflict with the goals of the paternity intervention. The chief one is the pressure to submit the birth certificate worksheet to BVS as quickly as possible. Often, this prevents clerks from giving unmarried parents time to think about the paternity decision. They may be reluctant to return to the mother's room later in the day or the next day after the father of the child may have visited. Since few are notary publics, clerks may also be unable to complete the paternity affidavit by themselves and must go through the time-consuming step of referring the parents elsewhere to obtain a notarized signature when notarization is necessary. Birth registration clerks may also worry about being unable to answer questions that unmarried parents have about benefits, child support and other implications of the paternity decision. They may also be reluctant to deal with delicate situations that involve both a husband and a putative father. They may resent an added responsibility with no change in their remuneration or support. They may be reluctant to become involved with what they perceive to be a "legal" issue. Due to staff turnover, they may require continual training and oversight to detect training needs. Finally, as hospitals strive to cut costs, some birth registration clerks are being terminated or cut back. Parents are being required to complete all vital statistics forms on their own. This trend may eliminate the possibility for an in-person presentation on paternity and/or any in-person assistance with completing the paternity affidavit.

Hospital Volunteers

The project has used hospital volunteers on a limited basis in the in-hospital paternity effort. Hospital "grandmothers" who volunteer on the postpartum floor have served as translators for paternity workers when presenting the overture to never-married mothers who only speak Spanish. The volatility of many volunteer work schedules and the competing demands placed by hospital staff for their limited time make volunteers of limited utility for in-hospital outreach efforts.

E. Other Obstacles

Public Health Concerns

The most commonly cited concern about introducing the paternity orientation in hospital settings has to do with its implications for the mother's willingness to seek medical care. Many doctors and nurses who work with mothers and babies fear that the paternity intervention will discourage unmarried parents from seeking prenatal care if it is perceived to be a "crack down on deadbeat dads." They are eager to preserve the public view of the hospital as supportive and friendly to poor parents.
The project attempted to allay these concerns by assuring medical and nursing personnel that the paternity establishment process is totally voluntary and confidential. While there are child support implications to paternity establishment, which are disclosed, the two are treated as independent processes. Indeed, under project procedures, paternity affidavits were returned to BVS and were not sent to DDSS. The child support agency refrained from initiating any child support action against fathers until the agency came upon the statement of paternity in its normal course of business.
Although all four hospitals in the Denver project ultimately supported the voluntary acknowledgement procedure, the approach they approved ensured the parents' confidentiality. In some settings where there is automatic reporting of paternity acknowledgements to the child support agency, patient confidentiality may be more of an issue. In these settings, proponents of paternity programs may have to wrestle with the potentially competing goals of gaining hospital support for promoting voluntary acknowledgements in hospital settings and obtaining child support orders most efficaciously by reporting voluntary acknowledgements to the child support agency.

Patient Comfort

It is universally acknowledged that newly delivered mothers are bombarded with information and interruptions during their ever-shrinking hospital stay. Most mothers spend only 24 hours in the hospital after delivering a baby. Hospital staff worry about the ethics and practicality of burdening these mothers during their brief stay with more staff visits, decisions, paper work and information. This is a concern expressed by both supporters and critics of paternity interventions in hospital settings.

Paternal Involvement

Nurses and hospital social workers are ambivalent about unmarried fathers and the impact of paternity acknowledgement programs on their participation and involvement. While some fear that the paternity overture (and its child support implications) will "scare fathers away" from hospitals and undermine "bonding" processes, others worry that the process will empower abusive men and invite participation from men who should be kept at a distance. There is also concern that current Colorado law does not adequately address the custodial rights of unmarried parents and that mothers who acknowledge paternity may jeopardize their custody status.

Ideological Issues

Frequently, hospital personnel are dubious that paternity establishment will have any practical benefit for babies and mothers. Some staff seem to resent the child support function and do not want to be part of a process they perceive to be primarily designed to reimburse the state for AFDC costs. Indeed, in one hospital, we discovered that one nurse who conducted daily discharge classes routinely advised unmarried mothers not to sign the paternity acknowledgement. Where the project was embraced most readily, the staff tended to support the involvement of fathers, including their assumption of financial responsibility.

Scheduling Prenatal Care

To date, it has been difficult to develop an effective way to make the paternity overture in prenatal settings. Many hospitals use an individual appointment format in the hospital setting or in private doctors' offices. This means that only a nurse or other staff person who normally sees pregnant women for prenatal care must make the paternity overture. Given workload considerations, staff turnover in hospital settings and the diffuse nature of office-based care, these individuals are generally not available for the dissemination of paternity information. Nor is there an efficient way to deploy specialized paternity workers when an individual appointment system is used. Timing is also an issue in programs targeted to the prenatal population. Unless the prenatal overture is made at a single, standard time point, like the first prenatal appointment, there is no practical way to avoid exposing pregnant mothers to program repetitions.
Clinics that use a group format best lend themselves to a group presentation, or a group showing of a video. This is how a paternity outreach with pregnant adolescents was handled at one hospital setting. In another adolescent pregnancy clinic, an attempt to present the paternity overture in the waiting room was abandoned because it was so difficult to get anyone's attention. In still another clinic setting, the hospital was reluctant to include paternity with other educational outreach efforts because it did not want to "offend" married women. It is clearly a challenge to routinely and efficiently reach pregnant, unmarried women and their partners.

Language Barriers

It has been necessary to develop arrangements to overcome language barriers when communicating with the never-married population. More than half of the unwed mothers delivering at Denver's largest public hospital are Latinas; nearly a quarter are Spanish-speaking and do not communicate readily in English. The project has succeeded in making the paternity overture to these women with the assistance of volunteer "grandmothers" on the postpartum floor. These women are willing to assist the social worker making the overture by translating the information for Spanish-speaking women. Spanish language brochures about the paternity option are also available for distribution. The project developed a Spanish language affidavit that was acceptable to BVS for interpretive purposes only.

Legal Concerns

Until July 1994, the paternity affidavit used in Colorado required a notarized signature for mothers and fathers. In many hospital settings, notary publics are in short supply. Relatively few birth certificate clerks and others who routinely work on the postpartum floor are notary publics. The practical consequence is that unmarried parents often had to hunt for a notary public to complete the affidavit, especially during evening hours when fathers are apt to visit. In addition, one Colorado hospital administrator objected to any hospital employee notarizing a signature on an affidavit for fear of potential hospital involvement in subsequent litigation about paternity. It appears that the substitution of witnessed signatures for notarized ones has resolved many of these problems.

Educational Outreach

Prior to the paternity project, none of the participating hospitals included the issue of paternity in the educational outreach they did with pregnant and newly delivering mothers. As a result of the project, all hospitals have incorporated the issue of paternity in presentations they make to pregnant adolescents. One useful resource is a seven-minute video on the benefits of paternity, and the importance of establishing it at birth, which can be shown individually or to Lamaze class groups or other group settings.
Although paternity education is beginning to be integrated with more pervasive information programs dealing with health and baby care, there continue to be obstacles to its more widespread use. One stumbling block to educational outreach is the fact that, with the exception of hospital programs for pregnant adolescents, there are few services explicitly targeted for unmarried parents. Another obstacle is that paternity continues to be poorly understood by hospital personnel who are frequently new on the job and have not been exposed to specific training on the issue.

F. Summary

Colorado's pilot project has shown that there are many legal, administrative and procedural challenges to be overcome in implementing a program to enhance voluntary acknowledgements in hospital settings. The most important requirement is a simplified, streamlined acknowledgement process. Voluntary paternity acknowledgement forms must be understandable; the process must be fast and free of charge; finally, it is helpful to avoid notarization and to rely on witnessed signatures.
A second necessary ingredient to an effective acknowledgement process is reaching pregnant, and newly delivering, unmarried mothers and their partners in hospital settings. Operating in hospitals requires addressing a host of practical and ideological considerations. This includes the issues of scheduling, language barriers, hospital image, and restrictions on patient contact. Program architects will also encounter a wide variety of reactions by hospital staff ranging from support, to doubt that paternity has any practical value for mothers and babies and to fears that aggressive paternity and child support efforts will discourage unmarried mothers from seeking prenatal care or encourage fathers to visit who are abusive. There are pros and cons to using various types of personnel to make the paternity overture. Finally, prenatal overtures pose particular challenges with respect to timing, scheduling and identifying the relevant target audience. One promising way to present paternity information to pregnant women is to combine it with broader educational outreach efforts dealing with issues like nutrition, labor, delivery and baby care, although there are few programs explicitly targeted to unmarried parents with the exception of adolescent pregnancy programs.
The final component of a successful, in-hospital acknowledgement procedure is a positive relationship between the agencies responsible for child support and birth registration. In-hospital grams will be more successful if personnel in vital statistics and child support agencies cooperate with one another to: develop mutually agreeable paternity acknowledgement procedures and materials; provide training on paternity acknowledgement and its implications to birth registration personnel; and generate timely, hospital-specific performance information on rates of voluntary acknowledgements in order to identify future training needs.
Finally, in order for child support agencies to maximize on the benefits of voluntary paternity acknowledgement and facilitate the process of establishing child support orders, it is also vital that there be an automated interface between the two agencies. Minimally, child support workers should have the capacity to screen birth certificates from their computer terminals in order to distinguish cases which need paternity establishment from those with voluntary acknowledgements.