In-Hospital Paternity Establishment:Experiences and Meaning Perceived by Unmarried Parents
Voluntary paternity establishment was placed in birthing hospitals by an act of Congress, but little is known about how unmarried parents experience this process. This study presents reactions from 81 racially/ethnically diverse, low-income parents. A qualitative analysis of semi-structured interviews revealed three overall themes and six subthemes: (1) paternity establishment process [subthemes: variety of experiences, strong emotional experience, and poor timing]; (2) meaning of paternity establishment [subthemes: responsible fatherhood, symbol of commitment to child, and importance of the child knowing his father's identity]; and (3) paternity establishment decision-making. Many parents either did not recall receiving the requisite information or found it difficult to focus on technical materials immediately after childbirth. For parents, the symbolic value of the father's name on the birth certificate overrode other considerations. Parents' perspectives may help administrators of paternity establishment programs better tailor procedures and timing to the needs of unmarried parents.
Paternity, birth certificates, single parent, fathers, decision making
Paternal involvement prenatally and after childbirth has direct links to birth outcomes and early childhood health, including infant mortality, low birth weight, preterm birth, and cognitive development.1–3 The beneficial effects of a father's involvement on his child's well-being have been recognized for decades,4 leading public health and health care leaders to call for more active facilitation of fathers' relationship to their children, particularly during the critical periods of infancy and early childhood.5,6
Focusing on the father-child connection is especially important in the context of unmarried parenthood because non-marital births constituted more than 40% of all births in the U.S. in 2015, including 60% of births to women under age 30, and the majority of births to mothers who were American Indian, Hispanic, or Black.7 Compared with married parents, unmarried parents have lower levels of educational attainment [End Page 497] and lower incomes8 and children born to unmarried parents are more likely to live in poverty.9 The Fragile Families studies found that at the time of birth, over 80% of unmarried parents were romantically involved, about half were living together, and the vast majority of both parents reported a desire for the father to be involved with his child.10,11
While legal fatherhood is automatic for married fathers, unmarried parents must first establish the father's paternity either through a voluntary acknowledgment of paternity or a court order. Research has shown that unmarried fathers who voluntarily establish paternity in the hospital are more likely to remain involved in their children's lives through frequent contact and overnight visits than fathers who establish paternity elsewhere or not at all.12 A meta-analysis of studies of nonresidential father involvement concluded that a father's involvement in his child activities was associated with positive benefits in terms of social, behavioral, cognitive, and psychological outcomes in childhood and adolescence.13
The benefits for the child of a legal father include access to the father's health history; health, dental, or life insurance; Social Security and veteran's benefits; and inheritance. Legal fatherhood obligates the father to pay child support if the mother receives Temporary Assistance to Needy Families (TANF) and is a prerequisite to obtaining a court order for legal custody and parenting time for fathers.14,15 The time during which voluntary paternity establishment most often occurs is during the hospital stay for the child's birth, which is when most parents receive information about paternity establishment and its legal implications for the first time.15,16
The voluntary paternity establishment process was placed in birthing hospitals by an act of Congress in 199317 because it was believed that fathers were more likely to be present during childbirth and that both parents would be more amenable to establishing paternity at the time of childbirth.14 Subsequent federal legislation in 1996 required paternity establishment as a prerequisite to adding the father's name to the child's birth certificate and the provision of information, orally and in writing, about the alternatives to, legal consequences of, and rights and responsibilities that arise from acknowledging paternity.18 Despite these requirements, a literature review suggests that many parents erroneously believe the father automatically shares legal custody at the time of his child's birth,16 and do not discover until the relationship dissolves that the mother controls the father's access to his child.19
Information about how unmarried mothers experience the process of paternity establishment remains scant; there seems to be no published research on the perspectives of unmarried fathers.16 The Paternity Establishment Study conducted in Texas surveyed unmarried parents about their reasons for choosing whether to acknowledge paternity in the hospital, but too few fathers completed the survey to constitute a representative sample.15,20 The most frequently endorsed reasons by mothers were being able to put the father's name on the birth certificate, ensuring their child has a legal father, and feeling it was the right thing to do. The authors described these responses as seeming to "underscore the symbolic and emotional importance of paternity establishment, rather than the instrumental or financial importance."20[p.27] The present study seeks to fill this gap through qualitative analysis of semi-structured interviews with low-income, unmarried parents. Better understanding how parents experience this may [End Page 498] help policymakers, health care systems, and practitioners to serve unmarried parents more effectively.
This study was approved by the Minnesota Department of Health Institutional Review Board (IRB 14-339). Representatives from seven social service agencies that serve low-income families in Minneapolis-Saint Paul, primarily African Americans and American Indians, assisted with the recruitment of participants. Some parents then referred other parents. Referrals from both sources continued until the target sample of 40 mothers and 40 fathers was achieved. Prospective participants were provided with contact information for the research staff. During a brief telephone or in-person interview, a research assistant described the study purpose and requirements and screened prospective participants for eligibility: having a child within the past five years, being age 18 years of age or older and unmarried at the time of that child's birth, and willing to discuss barriers unmarried fathers may experience when trying to be involved in their children's lives, such as paternity establishment, custody, parenting time, or child support. We chose to interview only one co-parent from a dyad in order not to exclude co-parents whose partner relationship had ended.
The interview process
Interviews were conducted in person between October and December 2015. Two research assistants conducted all but one of the interviews, 80% of these by the lead author. The remaining interview was conducted in Spanish by a bilingual researcher. Participants selected the location, often a community site such as a library. Interviews typically lasted about an hour. Participants provided signed consent for the interview and for audio recording and received a $50 gift card in compensation for their participation. Audio tapes were transcribed by an independent contractor and reviewed for accuracy by the research team.
As a basis for developing the parent interview guide, the researchers interviewed 35 institutional experts who interacted with unmarried parents about their perceived barriers to non-marital father engagement. These experts included government employees, father advocates, legal services providers, social service providers, program administrators, and others who help parents navigate the child support, criminal justice, and social service systems. Based on the issues they raised, the semi-structured parent interview guide addressed ways that fathers can be involved during pregnancy and after birth, challenges to involvement, the in-hospital paternity establishment process and informational materials, decision-making related to paternity establishment, and putting the father's name on the birth certificate (including whether child support obligations or the effect on public assistance played a role), and asked for recommendations to improve the in-hospital process.
Analysis of the data was conducted using Braun and Clarke's21 phases of thematic analysis in NVivo software version 9.22 All three authors read the transcripts to familiarize themselves with the data. After reading the entire data corpus, the researchers selected all data relevant to paternity establishment to create the data set used for the analysis presented in this report. The first and second authors developed a coding scheme based on information obtained through the interviews with institutional [End Page 499] experts and published literature and then incorporated notes from parent interviews. They revised the coding framework, adding new codes for information in the data that was not captured by the initial framework and modifying existing codes to fit with the data better. The coding framework included codes that represented answers to specific questions as well as topics that spanned the entire interview. Then the codes were organized into the broader level of themes and sub-themes. The coding team revised the themes as needed until the final themes were produced, then reread the entire dataset to ensure that the results of the thematic analysis maintained a good fit with the entire body of data and that all relevant data were included in each theme. The coding team used an a priori determined Cohen's kappa coefficient as a measure of inter-rater agreement (questions about recognition of an event were set at.80 level, and questions exploring a topic were set at.65 level). If agreement did not reach the desired level, the team met to identify next steps to calibrate the coding.
The sources of quotations used in this paper are identified by "F" for father and "M" for mother followed by their interview number.
The study sample consisted of 40 fathers and 41 mothers. Some parents spontaneously identified their race/ethnicity when responding to questions and others responded to an open-ended racial/cultural identity question at the end of the interview. Fifty-three parents characterized their identity as a single race or culture: 41 as Black or African American, eight as Native American, three as White, one as Hispanic, and one simply as Creole. Twelve parents identified as biracial: four as Black and Native, two as Black and White, two as Native and Hispanic, three as Native and White; one did not specify a race combination. For 16 parents, racial/ethnic data were unavailable; two parents declined to answer the question; and for 14 parents missing data resulted from an interviewer skipping the question because of time constraints or choosing not to probe. Several parents responded with other social descriptors such as: "a guy who lived in poverty all my life but my kids [are] taken care of," "urban," "blue collar," or "single mom working hard to provide for my child." Even among parents who provided a specific racial designation, their responses reflected some ambiguity or a desire to clarify, indicating that standard racial classifications may be inadequate from their perspective: "Irish in my blood, Asian in my blood [but] I identify as Black in culture and background;" "African American but also Indian, Irish;" "My mother's White and my father's Black but I go by African American;" "Hispanic meaning I'm not from Mexico… born in Texas." For one parent, family composition was described first: "My kids are biracial; their father is Black; I am White."
Analysis identified three overall themes and six subthemes. The overall themes are (1) paternity establishment process, (2) meaning of paternity establishment, and (3) paternity establishment decision-making. Subthemes related to the process are variety of experiences among parents, strong emotional experience, and poor timing. Subthemes associated with the meaning of paternity establishment are responsible fatherhood, symbol of commitment to the child, and importance of the child knowing his father's identity. [End Page 500]
Paternity establishment process
Variety of experiences
Parents reported a wide variety of experiences related to whether and how the information concerning paternity establishment was presented, the level of detail hospital staff provided, and their measure of satisfaction with the process. They varied considerably in their recall of which materials they saw. While a majority of parents could recall the paternity acknowledgement form, a large number could not recall the informational booklet, and almost none recalled viewing the video.
Parents also reported varying experiences with hospital staff, from no discussion or only a perfunctory delivery of the educational materials to more substantive discussions. For example, one father said, "All they did is just came, handed us the papers and that was it" (F36). One mother said, "They talked to me a little bit about [the form] and they said that [it] will just basically help them determine what to put on the birth certificate" (M33). Another father said:
They did let me sign it, but none of this information was given… just here, sign right here. I said what is this? This is the Recognition of Parentage. Oh, okay. Is this a birth certificate? No, it's a Recognition of Parentage. Where's the birth certificate? Well we sign this, and then they make it. That was it.(F19)
Some parents who received little explanation up front said that hospital staff later offered them the opportunity to ask questions; other parents reported that the hospital staff comprehensively explained paternity establishment to them, for example:
Yeah, they talked to us about the form… explained about why it was, because we were not married, and just kind of basically to recognize that he is the father. That he was willing to say yes, this is my child, without having to provide the DNA and all that, because we weren't married… when you sign this paper, they explain everything to you about it.(M14)
Varying experiences with provision of information led to variable reactions. Some parents reported that the presentation was informative and helpful—even when it provided minimal explanation—while others believed that more explanation should have been provided. Some parents who did not understand the consequences of acknowledging paternity until later reported strong feelings of dissatisfaction with the level of information they had received in the hospital.
Strong emotional experience
Even amid the heightened emotion that accompanied the birth of their child, many parents experienced the process of establishing paternity—especially putting the father's name on the birth certificate—as particularly emotional. With only a few exceptions, the strong emotions reported by parents during this process were positive, with the most commonly identified emotions being pride, happiness, and excitement. For example, one father described his feelings at the time this way:
I felt good about it… like I just signed ownership of my own home. My own. You know, that's mine. Proud of it. Proud of it. Doing something. You know like buy a house, I bought it, it's mine. Stamp of approval.(F27) [End Page 501]
Similarly, one mother discussed the feelings her children's fathers had:
I feel like a father is more happy to sign the birth certificate. I just feel like it makes them more so reassured that this is my child, I'm going to be in this child's life… . When the father's signing the birth certificate, a lot of times, I see fathers smile, they're excited, they're happy. This is theirs, they're signing it.(M28)
Parents identified challenges related to the timing of the process so soon after childbirth. Many reported being overwhelmed by the childbirth experience with little ability to attend to anything else. Some wanted to focus only on caring for their baby at that time. One mother characterized hospital staff trying to present the paternity establishment material as an intrusion: "It's always when you're doing something, when you're giving the baby his or her first bath, or when you're trying to latch the baby onto the breast… it's always they're coming in at that time" (M13). Some parents alluded specifically to completing the paperwork quickly. For example, one father said: "It was just fill out this paperwork. This is my son's name. This is for a Social Security card. This is for his birth certificate. Signed them, and I was happy, got to get back to my son" (F14). Mothers often reported needing rest after giving birth and not having the energy to examine paternity establishment materials closely. One mother, speaking about the informational video that hospital staff were required to show, said,
I just got done having a baby. I was more tired and not ready to sit up and actually watch a movie. It was so close after I had my baby. I really just wanted to sleep. That's really what you want to do after you have a baby… so that's basically what I did during the movie. I wasn't up to watching a movie.(M06)
Parents who were focused on their newborn and mothers who were exhausted following childbirth recommended altering the timing of the paternity acknowledgment. They thought it would be helpful to have the information provided to parents before the child is born as well as for parents to have more time to complete the process in the hospital.
Meaning of paternity establishment
Fathers reported that they viewed paternity establishment—more specifically, putting their name on the birth certificate—as integral to their understanding of responsible fatherhood. Describing his reasoning, one father said,
Well, just because they're my kids. I mean I'm going to be on their birth certificate, 'cause I am their father and it's my responsibility, so I don't take that lightly. So yeah, if her [the mother's] name is on the birth certificate, so is mine.(F26)
Many fathers emphasized notions of manhood and fatherhood, for example:
Well, this is your baby, you're going to sign for it, you're going to man up. And of course with our pride, there we are, right, you know. Ready to do the right thing, or what we think is the right thing.(F12) [End Page 502]
For fathers, putting their name on the birth certificate represented moving into fatherhood and manhood and confirmed their identities as responsible and honorable. Although this theme was mentioned most often by fathers, a few mothers also addressed responsible fatherhood.
Symbol of father's commitment
Parents reported that establishing paternity symbolized the father's commitment to his child and demonstrated that commitment to others. Some parents reported that this would also demonstrate that commitment to the child later on:
The type of person I am, I don't want to be considered deadbeat… I gotta leave some type of trail like dad tried, you know? I did what I had to do. I did what I could do to the best of my ability, you know? I never forgot about you guys. It ain't like I just had you guys, oh bye.(F03)
One mother described the potential impact on the child based on her own childhood experience: "It's something to feel like you belong, something to feel like you're accepted, something to feel like someone claimed you. I always wanted that for my kids, because I didn't feel that way" (M24). Another emphasized the co-parent partnership:
I think another benefit for the mother is just feeling that when you sign a birth certificate you're signing this partnership that you're accepting this as your child. This is my child, and we know together that we can do this. Family or co-parenting or living separately—it just brings a certain amount of peace over the woman.(M07)
Fathers felt that by acknowledging paternity their role was also recognized by others outside the immediate family. One mother described her partner's joy at finally experiencing this recognition:
I mean it was actually a good thing, because he was happy that he could finally be recognized and take that stand, as "I am the father." At first it's just he's there, and all the attention is on me and baby. But with this, he was able to be involved, and be recognized as the father.(M09)
Mothers and fathers both reported that a father not acknowledging paternity would signal that he was not ready to become a committed father. One mother said, "I felt that way because if he doesn't sign the birth certificate, that means he doesn't want to be part of my child's life" (M29).
Children knowing their father's identity
The final sub-theme pertains to reports by both mothers and fathers of a long-term benefit for their children of knowing who their father is and understanding their family history. Parents expressed the belief that having a father's name on the birth certificate demonstrates to the child with certainty who the father is. Talking about why the mother wanted his name on the birth certificate, one father said, "She want the name on there because that's something, it's only right to do that… so the child do know that the father is their father" (F09).
A few parents spoke about the importance of the child receiving the father's last name as a symbol of their familial ties. One mother explained, [End Page 503]
For men, I think that it's carrying on their name. Especially if it's a son, being able to pass down their life, their last name, because that's important… sometimes we just want to know who we are, where we come from, and a last name means something.(M07)
Parents also saw establishing paternity as an advantage so children would be able to look up their father and their own ancestry or family history. Parents often spoke of situations in which the father is not involved or the father or mother passed away. In these situations, parents believed having the father's name on the birth certificate would protect the children by allowing them to know their family history. One father explained,
Just say you pass away before he grows up, he didn't get to know you. If your name is on his birth certificate, he can look you up, do his background history. The mother might not get along with his family, so she might not let the kid go see the family. So when he gets older, he can do that stuff his self.(F15)
Paternity establishment decision-making
The third main theme pertains to the ways in which parents approached the decision whether or not to establish paternity. Just under half of the parents described their actions not as the result of a calculated, pragmatic decision, but rather as "a given." Others were influenced by the consequences as they understood them. The pragmatic considerations identified by parents included the effects on child support, public assistance, child custody, parenting time, tribal enrollment for Native Americans, as well as doubts about paternity.
In response to a question about their decision-making, fathers often used phrases and words such as, "automatic," "no questions," "no-brainer," and "didn't think twice." Mothers often responded similarly: "logical," "why not?", "a must," and "never a doubt." One father explained his decision by saying,
I put my name on most of my birth certificates, because they're mine, so not really sure what people debate about… . For the most part, most of the people that I know, that really wasn't up for discussion. That was just pretty much given, you know.(F37)
One mother described her experience and that of her co-parent this way: "It's kind of like a no-brainer. Like for me and my son's father… it was just kind of like, I fill out my portion, you fill out your portion. That was kind of it" (M01). When parents endorsed the symbolic and moral meaning of the birth certificate, they gave little deliberation to their decision. For example, one father invoked his sense of responsible fatherhood: "It's just what you do. It never came into my mind not to put my name on the birth certificate. It was just a given" (F20).
Some parents who approached the decision this way lacked awareness of the legal consequences associated with paternity establishment. For others, the symbolic and moral dimensions of paternity establishment superseded any legal consequences they were aware of. Sometimes, this foregone decision resulted in parents' disinterest in learning more about the legal consequences of paternity establishment. For example, one father described his reaction to the information that was presented to him in the [End Page 504] hospital by saying, "They asked, 'Did you want to read this?' I told them, 'What for? I'm his dad'" (F28). Some parents were well aware of the legal consequences, even those they viewed as potentially problematic, but did not let these consequences influence their decision. For example,
If you sign that, you're f***ed, basically. Like if you sign that your life's over. You're not going to be able to get to where you want to be in life, because you're always going to have this person on your back. So that's what I got from it, you know? I still get that a lot… did you sign the papers? Like hell yeah I'm signing my baby's papers. Because I know what I'm going to do, I know what I'm capable of doing.(F03)
Other parents emphasized the legal implications and made their decision accordingly. Parents mentioned some legal benefits to establishing paternity, including tribal enrollment benefits for Native Americans, and for some mothers, the ability to open a child support case if the father was not involved. Some parents cited the erroneous belief that the father would be granted custodial rights as their motivation. A small number of parents believed that not establishing paternity would be the best decision; their reasons included fear of the child support system, implications for mothers receiving public assistance, and doubts about the identity of the biological father. One father reported not completing paternity establishment in the hospital in order to delay the start of child support:
I thought about child support when I first got my kids, and I denied them only because I wanted to go through the procedure of blood testing and the state would pay for that back then… and so it gave me time to… save some money.(F30)
Another father also spoke of not wanting to establish paternity because of fear of child support enforcement penalties:
If you're not married… at some time or another, the support issue's going to come up, and a lot of other things that discourage a lot of fathers from putting their name on the birth certificate because they want to keep having them tax checks, and they don't want their driver's license taken away.(F12)
Researchers have noted the absence of parents' own perceptions of the process and significance of paternity establishment, particularly the lack of input from fathers.15,20 This study helps fill this gap in the literature. Our study findings are consistent with past research on mothers that found paternity establishment to be a highly symbolic and emotional experience.15,20 We found that fathers and mothers both ascribed importance and symbolic value to paternity acknowledgement and the father's name on the birth certificate. Fathers spoke of how establishing paternity aligned with their sense of responsibility and identity as fathers and men. Mothers and fathers also spoke of how acknowledging paternity demonstrates that fathers are committed to their children and [End Page 505] would allow them to know their father's identity in the event he passed away before they got to know him.
Our findings add to existing research by illustrating how the meaning parents attributed to paternity establishment influenced their experiences and their decision-making. The symbolism and responsibility of fatherhood appeared to preclude more pragmatic considerations for many parents and even led some to disregard the information hospital staff were required to provide. The timing of the in-hospital process also amplified the challenges associated with understanding the legal implications of paternity establishment. Consistent with past research,15,20 parents in this study described childbirth as a time of heightened emotion and a time to focus on recovery and being with their child, making the timing of the paternity acknowledgment process and requirements intrusive and burdensome. Our findings related to parents' misperceptions about the father's custodial rights also echoed earlier research.16,19
Study results also provide important insights for hospital staff and program administrators. Some of the difficulties and shortcomings parents described may be due to a variety of factors, such as differences in parents' needs and comprehension, hospital procedures, staff members' presentations, staff training, and demands of staff due to the number of admissions. The in-hospital paternity establishment process could be improved by ensuring that parents are given comprehensive information, sufficient time for a thorough explanation, and opportunities for questions and discussion. However, even a consistent, thorough process may not overcome parents' significant concerns regarding the timing. Because new parents' emotional states may override their desire or ability to process technical information, offering the information earlier as parents suggested—during childbirth classes, after prenatal care appointments, or during tours of hospital labor and delivery areas, for example—would allow them to digest information, get or plan for a DNA test, and consider their decision under less highly charged circumstances. The Texas Attorney General's Office has developed a system that substantially addresses the issues raised in our study relative to the timing of paternity acknowledgment and the thoroughness of information parents receive;23 parents have access to information and can even sign and submit the paternity acknowledgment form before their child is born.
The study has several limitations. Enrollment was voluntary, so we may have been more likely to attract parents who had strong feelings they wanted to express. Parents were also reflecting on their experience with up to several years of hindsight, which may have affected their recollections. Finally, perspectives from parents who were not together in the months leading up to childbirth or mothers for whom the father was not identified or involved are likely underrepresented. Despite these limitations, the study results are important for presenting the perspectives of unmarried parents, especially those of fathers, about the in-hospital paternity establishment process. Because the parents we interviewed so clearly identified their concerns, they provided direction for developing a process that more accurately reflects their needs and desires and allows them to focus on their joy and excitement at the time of their child's birth. [End Page 506]
PAUL A. REBMAN is a fellow with the Global Health Corps, placed in Kampala, Uganda. MAGEEN C. CAINES is a Senior Public Health Researcher/Epidemiologist, Minneapolis Health Department. PATRICIA A. HARRISON is Director of the Research and Evaluation Division, Minneapolis Health Department.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under MCH Research grant number R40MC26807 (total award $871,448). This content and conclusions are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.