Chapters 1-3

Chapter I: The Paternity Problem
Chapter II: Legal, Procedural and Administrative Considerations in Implementing In-Hospital Paternity Acknowledgement Efforts
Chapter III: Baseline Research: Paternity Acknowledgement in Colorado in 1991

CHAPTER I

THE PATERNITY PROBLEM

     Colorado, like the nation as a whole, has experienced a
dramatic rise in the number of births to unmarried women. In
1950, only 3 percent of all births in Colorado occurred out of
wedlock.  By 1991 the proportion had increased to 23.6 percent.
Nationally, the rate of non-marital births was 30.1 percent in
1992.

     Although recent evidence shows a rise in out-of-wedlock
births among women in their twenties and thirties and with higher
levels of educational and occupational attainment (Bachii, 1993),
unmarried parentage is still concentrated among the poor and is
associated with further impoverishment.  The most disadvantaged
demographic group in the U.S. is children of single-parent
families (Garfinkel & McLanahan, 1986).  Within this group,
children living with never-married mothers are the poorest.  In
1992, 55.8 percent of Colorado families receiving Aid to Families
with Dependent Children (AFDC) were eligible because of
father-absence due to non-marriage (Green Book, 1994: Tables
10-35).

     One factor contributing to their low incomes is the fact
that most never-married women fail to become eligible to receive
child support.  Nationally, it appears that only about
one-quarter of the never-married mothers had established
paternity for at least one of their children in 1986. This was
corroborated in a  1990 survey of Colorado households where only
one-quarter of the unmarried parents had established paternity
through legal action (Pearson, Anhalt and Thoennes, 1991).  In
fiscal year 1992, paternity had been established in only 27
percent of AFDC households with an absent father due to
non-marriage (Green Book, 1994: Tables 10-35).

     As a result of the low rate of paternity establishment, most
never-married women never get a child support order.  Census data
reveal that only 24 percent of never-married women have a child
support order and are legally eligible to receive support.  In
contrast, 77 percent of all divorced women have child support
orders (U.S. Bureau of the Census, 1991). Once a child support
order is obtained, never-married women are equally likely to
receive payment as their divorced counterparts.  Thus, regardless
of their marital status, about half of the women with child
support orders receive full payment while a quarter receive no
payment at all and another quarter only receive partial payment.
However, since average annual child support receipts for
never-married women fall below receipts for separated and
divorced women, even never-married women with child support fare
badly economically.  Taken together, the average never-married
woman received only $273 annually in child support compared to
$951 for separated women and $1,776 for divorced women (U.S.
Bureau of the Census, 1991).

     Not surprisingly, poverty rates are extremely high for
never-married mothers and their children. In 1989, 54 percent of
never-married women with minor-aged children lived below the
poverty level.  For divorced mothers with minor children, the
percent at or below the poverty level was 27 percent.  For all
families with children, the percent at or below the poverty level
was 15 percent (U.S. Bureau of the Census, 1991).  Further
evidence of the disadvantaged status of never-married mothers and
their children comes from profiles of participants in the Aid for
Families with Dependent Children program.  In 1987, 57 percent of
single-parent AFDC children were born out-of-wedlock, while 40
percent came from parents who were divorced or separated (Meyer,
1992a).  Never-married women on AFDC tended to receive assistance
the longest.  On average, divorced women received 4.9 years of
AFDC while never-married women received AFDC for 9.3 years
(Ellwood, 1986).

     Patterns in Colorado track with the national profile. A 1990
survey of Colorado households revealed that more than half of the
state's never-married women with minor-aged children lived below
the poverty level. Unmarried parents likely to have child support
orders had court-ordered paternity.  Only 32 percent of women
with birth certificate-acknowledged paternity had child support
orders and another 18 percent had informal, written agreements
(Pearson, Anhalt & Thoennes, 1991).

     Children born out-of-wedlock experience other deprivations
along with financial ones. For example, they have the lowest
levels of contact with absent fathers.  In a Baltimore study of
teenage childbearing, only about a third of the never-married
fathers saw their adolescent children at least once a month.
Evidence from the 1981 National Survey of Children showed even
lower levels of contact--21 percent of the black youth and 6
percent of whites between the ages of 11 and 16 whose parents
never married had seen their father once a month or more in the
past year (Furstenberg and Cherlin, 1991).

     The establishment of paternity in unmarried births is seen
as one way to address the deprivations associated with
out-of-wedlock parentage.  Among the recognized medical benefits
to paternity establishment is knowledge about the father's
genetic background, including potential inherited disorders which
allow appropriate medical care to be provided, and the
possibility of the father being the life-saving donor of
bone-marrow, a kidney or other organs in a medical emergency. The
emotional and psychological benefits of paternity include the
opportunity to identify with the paternal half of a child's
ancestral roots, and to know and explore family heritage, culture
and religious ties.  Paternity may also lead to the opportunity
to establish a parent-child relationship and the exercise of
paternal contact and access to the paternal family (Hoover,
1991).

     Among the many social entitlements that ensue from paternity
are the ability to realize inheritance proceedings, survivor
benefits through social security, and dependent benefits under
workman's compensation if the father is injured on the job. If
the father is a member of the armed forces, or becomes a member,
paternity can lead to monthly dependent benefits, educational
benefits and military health care and insurance.

     Finally, paternity establishment may lead to important
financial benefits.  Evidence of paternity is needed if the
mother wants child support.  Evidence of paternity can also lead
to dependent health care coverage if the father's employer has
insurance and a share of unemployment compensation if the father
is unemployed.  The fact that many unmarried fathers have little
or no income when their babies are born does not mean they will
always have limited means.  For example, while more than half of
teen-aged fathers have zero incomes at the time the paternity
petition is filed, less than 20 percent have zero  incomes at age
30.  A recent study showed that, on average, income for fathers
in paternity actions increased by $4,000 during the three years
following the filing of the paternity petition (Meyer, 1992b).

     Despite the benefits of paternity establishment to the child
and to society as a whole, performance in paternity establishment
has been exceptionally poor.  Paternity cases have historically
received low priority in child support agencies (Bernstein 1982;
Kohn 1987).  Accordingly, few children of unmarried fathers have
paternity established, get child support orders or obtain
support.  For example, in 1988, the paternity establishment rate
for the nation as a whole stood at 30 percent.  Thirty-two states
scored below 30 percent; forty-five scored below 50 percent
(Office of Inspector General, 1990).  In April 1987, the General
Accounting Office found that 4 of every 10 AFDC children who
needed paternity determinations for support orders (41 percent)
did not receive them because their cases were never opened, were
closed prematurely or remained open but unattended (G.A.O.,
1987).

     Paternity researchers are unanimous in concluding that the
best time to establish voluntary paternity is at the time the
child is born and that the likelihood of establishing paternity
declines as children age (Danziger and Nichols-Casebolt, 1988).
The first year of a child's life has been termed "a window of
opportunity for establishing paternity" that is not encountered
at later stages in the child's life.  Indeed, the most
propitious moment for paternity establishment is at the hospital
at the time of birth.  For example, a study of unmarried
teen-aged parents found that 80 percent thought it was important
for the father's name to be on the birth certificate (Wattenberg
et al, 1991).  These researchers also found that the
opportunities for contact and success that are present at the
time of birth quickly fade.  A follow-up study one year after the
child's birth, which attempted to conduct interviews with young,
unmarried fathers and mothers, was thwarted by disconnected
telephones, letters returned "address unknown" and tracking
efforts that failed.  As a result of their experiences, these
researchers recommend the following steps:

o    Make paternity acknowledgement materials routinely available
     in hospital settings and focus attention on supporting the
     parents' decision to acknowledge paternity while mother and
     baby are still in the hospital.

o    Make materials (written and oral) in appropriate languages
     available to both parents which describe the benefits to
     children that flow from paternity acknowledgement.

o    Treat voluntary paternity establishment as an isolated issue
     and make it separate from issues such as child support,
     visitation rights and custody.

o    Combine paternity establishment with a more comprehensive
     information program geared to social services, health and
     other interventions for children, youth and families.

 o   Maintain existing exceptions in policy and procedure toallow
     for instances where the legal link of father to child should
     not be encouraged.

     In recent years there has been a "flurry" of legislative
initiatives aimed at obtaining paternity acknowledgements at the
time of birth.  One provision of the Family Support Act of 1988
required that states meet specific quantifiable goals for
establishing paternity (Maniha, 1992).  More recently, a federal
law was enacted requiring that each state develop a simple
administrative process for voluntarily acknowledging paternity
and create a hospital-based program for voluntary
acknowledgements (Omnibus Budget Reconciliation Act of 1993 [P.L.
103-66]).  The state with the longest experience with such
efforts is Washington, which passed a law in 1991 requiring that
medical records and hospital personnel provide written and oral
information about paternity and/or the opportunity for unwed
parents to acknowledge paternity.  Preliminary evaluation results
regarding the effectiveness of this hospital-based paternity
program in Washington are encouraging.  In a period prior to the
inception of  the in-hospital paternity effort, paternity
establishments for out-of-wedlock children aged 4-5 years old
occurred in only 17 percent of the cases.  Following the routine
use of in-hospital orientations, voluntary paternities rose to 33
percent of all relevant births in Tacoma General, the state's
largest community hospital serving a high concentration of
unmarried women (Hoover, 1991).   Washington estimates that 40
percent of unmarried births will be accompanied by
acknowledgements (Cleveland and Williams, 1992).

     In light of the obvious benefits of paternity, the Colorado
Department of Child Support Enforcement applied for and received
a Child Support Enforcement improvement grant (91-4-PI-CO-00) in
1991, one component of which was aimed at initiating a pilot
paternity demonstration. The multi-year grant involved
streamlining the voluntary paternity acknowledgement process in
severalDenver-area hospitals, and introducing and evaluating the
effectiveness of various efforts to disseminate information about
paternity in-hospital settings.  Since the award was made, the
project has involved the following:

o    Introduction of in-hospital paternity acknowledgement at
     four metro are hospitals.

o    Conduct of daily outreach efforts about paternity with
     unmarried mothers on an individual basis in postpartum
     settings in four metro area hospitals.

o    Simplification of the voluntary paternity acknowledgement
     process to remove procedural and financial barriers.

o    Development and enactment of a statewide law requiring
     medical institutions to grant unmarried parents an
     opportunity to complete an affidavit acknowledging
     paternity.

o    Joint discussions of paternity establishment by staff at
     Colorado's child support and vital records agencies leading
     to the production of the Handbook for Hospital-Based
     Paternity Acknowledgement.

 o   Production and distribution of English and Spanish
     languagematerials on  paternity and the acknowledgement
     process.

o    Edit of a 7-minute video on paternity acknowledgement to be
     used with unmarried parents in prenatal and postpartum
     forums.

o    Conduct of training on paternity acknowledgement for various
     hospital audiences.

o    Conduct of a comprehensive evaluation of the in-hospital
     paternity effort with emphasis on changes in rates of
     acknowledgement and the characteristics of those who
     acknowledge versus those who disavow paternity.

     The following chapters describe some of the lessons we have
learned in the course of implementing and evaluating Colorado's
paternity project.  In Chapter II, we describe the legal,
procedural, and administrative factors that came into play in
implementing an in-hospital paternity overture in four hospitals
in the Denver area.  In Chapter III, we discuss voluntary
paternity acknowledgement patterns prior to the initiation of the
pilot project.  In Chapter IV, we describe the impact of the
in-hospital outreach effort on acknowledgement levels.  In
Chapter V, we describe the demographic characteristics of
unmarried parents who voluntarily acknowledge.  In Chapter VI, we
present the financial correlates and consequences of voluntary
paternity acknowledgement.  In Chapter VII, we describe the
reasons for paternity acknowledgement and disavowal given by
unmarried parents themselves.  Finally, in Chapter VIII we
summarize project findings and discuss their implications for
policy.


CHAPTER II

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


     The Colorado Paternity Demonstration Project
involvedimplementing 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
routinelyinform 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 accommoda-
tions. 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
beestablished on a presumptive basis, there was no effort
toexplain 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.
Followingthe passage of state law requiring hospitals to make
thepaternity 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 andthe 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 informa-
tion 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 experimen-
tation, 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
theprospect 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
bythemselves 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-personassistance 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 acknowl-
edgements 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
mothersare 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
wasabandoned 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  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 ven-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 programs 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.


     CHAPTER III

              BASELINE RESEARCH:
              PATERNITY ACKNOWLEDGEMENT IN COLORADO IN 1991

     Is in-hospital paternity acknowledgement effective?  To
nswer this question, it is first necessary to generate abaseline
portrait of paternity acknowledgement prior to the introduction
of hospital-based efforts.  We accomplished this in Colorado by
commissioning the Department of Health to produce a data tape
containing information on the state's 12,668 out-of-wedlock
births during 1991.  This time period clearly preceded the
initiation of project and legislative activities in Colorado
aimed at enhancing paternity acknowledgement.

     Within the constraints of the data available on the birth
statistical abstract file, we conducted an analysis of the
characteristics of parents who opted to acknowledge paternity
versus their non-acknowledging counterparts.  This analysis also
examined patterns for the four Denver facilities in which the
paternity intervention was subsequently implemented.

A.   Highlights from the 1991 Analysis

     There were 12,668 out-of-wedlock births in Colorado in 1991.
They disproportionately occurred to Latina and African-American
women who resided in Denver. Like the nation as a whole,
unmarried mothers in Colorado tended to be poorly educated with
only 18 percent having more than a high school education. Nearly
half (45 percent) had at least one other living child at the time
of the 1991 birth.

     Father's name was entered on the birth certificate in 23
percent of unmarried births in 1991. Within three years of the
birth, another 6 percent had a father's name added as a result of
a court order. Overall, the likelihood of a father acknowledging
paternity on a voluntary basis increased if the baby was White
rather than of minority racial or ethnic status. Similarly,
voluntary acknowledgement increased with mother's educational
level, her employment during pregnancy, and the absence of prior
births. Voluntary paternity acknowledgement did not vary with
factors such as maternal age, prenatal care, low birth weight,
abnormalities of the newborn or prematurity.

     Selected characteristics of unmarried births in Colorado are
discussed in greater detail below.

o    The 12,668 out-of-wedlock births in Colorado in 1991
     comprised 23.6 percent of the total births in the state for
     that year.

o    Women with unmarried births ranged in age from 12 to 49
     years with an average of 22.7 and a median of 20.5.  Over a
     third of the women were in the 18-21 year range.

o    Babies born to unmarried women were primarily White (54
     percent), although Latinas (30 percent) and
     African-Americans (13 percent) were over-represented
     relative to their distribution in the state's population. In
     1991, Whites comprised 73 percent of all Colorado births,
     while Latinas and African-Americans comprised 18 percent and
     6 percent, respectively.

o    The average number of years of education for unmarried
     mothers was 11.5. Only 18 percent of the women had more than
     a high school education.  Approximately 42 percent had less
     than high school education and the remaining 40 percent had
     completed high school but had not gone beyond.

o    Forty-two percent of the women reported working during at
     least a portion of their pregnancy.   There was not enough
     information on annual income or occupational category to
     gain insights on these patterns.

o    Approximately a year following the birth, the father's name
     was entered on the birth certificate in 23 percent of
     unmarried births in 1991.  This included voluntary
     acknowledgements as well as those achieved by court order.
     By three years post-birth, the paternity establishment rate
     had increased to 29 percent.  Again, this includes voluntary
     acknowledgements and court-ordered establishments.

o    A few demographic characteristics available from the birth
     certificate correlated with the presence of the father's
     name. For example, a name was more likely to be entered if
     the mother was White (27 percent) rather than
     African-American (18 percent) or Latina (20 percent).  The
     likelihood of the father's name being entered increased with
     the mother's years of education.  Thus, names were added in
     29 percent of the cases where mothers had more than twelve
     years of education versus 20 percent of the ases where
     mothers had less than twelve years of education.

o    Women who had more than one previous birth were less likely
     to have the father's name entered (18 percent) than were
     those women with only one prior birth (22 percent) or no
     prior births (25 percent).

o    There was no indication that entering the father's name on
     the birth certificate was influenced by prenatal care
     patterns, low birth weight, abnormalities of the newborn or
     prematurity.

o    There was little variation in the percentage of cases with
     the father's name entered on the birth certificate by county
     of birth or mother's county of residence.

B.   Highlights from the 1991 Analyses of the Four Project

     Hospitals

     Colorado's paternity demonstration project was conducted at
four Denver area hospitals. These facilities had different
voluntary acknowledgement rates prior to the start of the
project. In 1991, voluntary acknowledgement rates in
participating hospitals ranged from 13 to 24 percent.  Within
three years, another 11 to 14 percent of unmarried births at each
hospital had paternity established by court order.

     Not surprisingly, unwed mothers who delivered at these four
hospitals had different demographic characteristics that appeared
to track with voluntary acknowledgement patterns. In general, the
highest voluntary acknowledgement rates occurred at the hospitals
with the highest rates of maternal education and employment.
Voluntary acknowledgement was also associated with the absence of
other living children, and White racial identification.
Conversely, hospitals with the lowest voluntary acknowledgement
rates tended to have patient populations that were heavily
non-White, poorly educated, unemployed and had other previous
births.

     Rates of voluntary paternity acknowledgement and court
ordered establishments at the four participating hospitals in
1991 are presented in Table III-1. Characteristics of the
unmarried mothers who delivered at the four project hospitals are
summarized in Table III-2. These patterns are discussed below.

o    There were 4,260 unmarried births in 1991 in the four
     hospitals that participated in the paternity demonstration
     project:  Denver General, Mercy, St. Joseph and University.

o    A comparison of the major facilities in Denver in which the
     project was subsequently implemented revealed sharp
     differences in the degree to which the father's name
     voluntarily appeared on the birth certificate.  The lowest
     rates occurred in Denver General where only 13 percent of
     unmarried births had a father's name on the birth
     certificate.  At the high end was Mercy, with a voluntary
     establishment rate of 24 percent.

o    Differences in paternity establishment rates across the
     participating hospitals appeared to be largely the result of
     differences in the patient populations that were served.
     For example, there were significant differences in the
     average education level of the women served in hospitals
     participating in the pilot, and education is known to
     correlate with voluntary paternity establishment.  In Denver
     General Hospital, only 6 percent of unmarried mothers had
     more than twelve years of education. At Saint Joseph, just
     over a quarter (26 percent) of the mothers had more than a
     high school education.

o    Another significant difference in the participating
     hospitals was the racial profile of mothers delivering
     out-of-wedlock babies.  At University and St. Joseph
     Hospitals, 49 and 44 percent, respectively, were White.  At
     Mercy, the proportion of Whites was 24 percent.  And at
     Denver General, the proportion of Whites was only 12
     percent.  Mercy had the highest proportion of
     African-American women (37 percent).  Delivering mothers at
     Denver General were overwhelmingly Latina (61 percent).

o    Unmarried mothers delivering at the four project hospitals
     had significantly different employment patterns during
     pregnancy with 53 percent reporting employment at St. Joseph
     compared with 20 percent at Denver General.  These
     differences persisted even when we restricted the analysis
     to mothers aged 19 years or more.

o    Unmarried mothers delivering at the four project hospitals
     had different numbers of prior births.  Mothers at Denver
     General Hospital were significantly more likely to have
     other living children (57 percent) than their counterparts
     at St. Joseph (35 percent) and University (49 percent).

o    There were no significant differences in the average age of
     unmarried mothers delivering at the four participating
     hospital sites.  Across all four sites it was 22.3 to 22.8
     years.


     Table III-1
     Voluntary Paternity Acknowledgement Rates and Court Orders
     in Project Hospitals in 1991 Pior to the Demonstration

     Table III-1 omitted.



     Table III-2
     Selected Characteristics of Unwed Mothers
     Delivering in Four Project Hospitals (1991)

     Table III-2 omitted.


C.   Summary

     An analysis of 1991 births to unmarried mothers in Colorado
revealed that the father's name was voluntarily placed on the
birth certificate in 23 percent of the cases within the first
year of the baby's life.  Within three years following delivery,
the proportion of establishments stood at 29 percent. Voluntary
paternity acknowledgement was correlated with certain demographic
characteristics of the mother.  This included ethnicity,
education and numbers of prior births.  Paternity was more apt to
be acknowledged voluntarily among White mothers, educated
mothers, and mothers with no or only one prior birth.

     These patterns are reflected in the demographic profile of
unmarried mothers who delivered at the four participating
hospitals in the paternity demonstration project.  In 1991, prior
to the start of the demonstration project and the initiation of
routine, in-hospital presentations about paternity, voluntary
acknowledgement rates ranged from 13 to 24 percent at project
hospitals.  These rates varied with the educational, racial and
employment profile of the unmarried populations served at each
facility.  The lowest voluntary acknowledgement level occurred at
the hospital site with the highest proportion of mothers who
were:  non-White; poorly educated; had many prior births; and the
lowest levels of employment during pregnancy.  Conversely,
acknowledgement levels were significantly higher at hospitals
where mothers were more apt to have at least attended high
school, worked during pregnancy, and had fewer numbers of prior
births.