Pattern of unreported negative birth experiences in the maternity ward

Abstract

Introduction

Denmark is one of the safest places for childbirth, yet some women report dissatisfaction with their maternity care. However, some negative birth experiences may remain unreported due to thresholds for complaining. The study aimed to identify patterns of unreported negative birth experiences and to quantify the extent of these dark figures.

Material and Methods

A survey was distributed to 3081 women who gave birth at a Danish hospital in 2022, resulting in 1022 responses (response rate = 33.2%). The women reported their birth experiences in categories based on the Healthcare Complaints Analysis Tool (HCAT), specifying problems, harm caused, and whether they had filed a complaint or intended to. Dark figure ratios regarding problems and harm levels were calculated by comparing unreported negative experiences to formally filed complaints based on the survey responses, covering each problem type and harm level.

Results

Of the 1022 respondents, 336 (32.9%) women reported negative birth experiences, yet only 26 women had filed complaints. The remaining 310 unreported cases comprised 787 problems across HCAT categories. The most frequent problems were about communication and quality. The highest dark figure ratios were found within the management domain comprising institutional processes (13.0) and environment (9.9). The dark figure ratios showed an inverse relationship with harm severity, being highest for minimal (19.5) and minor (21.2) harm levels and decreasing for moderate (5.5), major (4.8) and catastrophic (0.3) harm levels.

Conclusions

This study demonstrates a substantial underestimation of negative birth experiences when relying solely on formal complaints, with dark figure ratios ranging from 4.8 to 13, depending on the issue. The inverse relationship between harm severity and dark figure ratios suggests a threshold for filing a complaint, as the likelihood of reporting increases with greater harm. These findings provide novel insights into unreported maternity care experiences, highlighting the need to integrate patient experiences into healthcare improvements.

Patient complaints represent only a fraction of problems experienced during childbirth. Among 336 women with negative birth experiences, only 26 filed complaints, revealing a dark figure with up to 13 times more unreported issues. Integrating complaint data with dark figure estimates enables a more accurate assessment of the true scope and nature of patient‐perceived problems.

Key message.

The most frequent problems in unreported birth experiences concern communication and quality. The dark figure of negative birth experiences exists across all problem types and harm levels, highlighting a threshold for filing a complaint despite issues with maternity care.

1. INTRODUCTION

Denmark is one of the safest places for women to give birth. ¹ Since 2000, the infant mortality rate in Denmark has been declining to 3 per 1000 births. ² However, some women are dissatisfied with care, and some decide to complain about it, describing negative experiences in the maternity wards. The right to complain about substandard quality of treatment given by one or more hospitals is used by patients across diagnoses in Denmark, including women giving birth. ³ Although several studies show overall satisfaction with maternity care during hospitalization, there are areas with great dissatisfaction, especially concerning relational issues as well as continuity of care. ⁴ , ⁵ A Swedish study by Rudman and Waldenström examined women's postpartum care and found that women experience staff shortages together with the absence of information, support, and sympathy from the staff. ⁶ In particular, the lack of support is a problem that recurs under several themes in the study. ⁶ Examples of this lack of quality of maternity care in Sweden are also seen in Denmark. A Danish study found that most complaints about maternity wards at hospitals in the Region of Southern Denmark are about relational issues, including listening and respect, while the complaints at other wards are primarily about quality and safety. ³

Although complaints are filed about negative experiences in the hospital maternity ward, many negative experiences may go unreported. Some experiences may not meet the threshold for filing a complaint. This study aimed to identify the problem pattern of unreported negative birth experiences and quantify the extent of these dark figures to better understand the gap between patient experiences and formal complaints.

2. MATERIAL AND METHODS

2.1. Population and setting

Odense University Hospital (OUH) is a larger public university hospital in Denmark with approximately 4700 births annually. OUH has two maternity units: a mixed‐risk labor unit located in the city where the main hospital is placed and a low‐risk labor unit located approximately 28 miles away as a satellite department of OUH.

We conducted a survey study in which we invited women who had given birth at OUH to complete a questionnaire to describe their birth experience. We used 3081 unique person identification numbers to send the questionnaire to their electronic mailbox.

2.2. Questionnaire

A Danish language questionnaire was tested in a pilot study (unpublished data) inviting 500 women who had given birth at OUH between July 1, 2022 and December 31, 2022. The pilot study with 165 (33.0%) responding women qualified for the questionnaire for the present study. The pilot study population was not used in this study. For this, we used the remaining women who had given birth in 2022.

The questionnaire for the present study contained an opening question asking whether the women had a negative birth experience at OUH in 2022, allowing them to be stratified for the subsequent questions. The women reporting a negative birth experience were asked to categorize and describe their experience based on the Danish version of the Healthcare Complaint Analysis Tool (HCAT). ⁷ HCAT is a valid and reliable taxonomy for analyzing patient complaints based on three domains: clinical, management, and relationship, with seven underlying problem categories: quality, safety, environment, institutional processes, listening, communication, and respect and patient rights. ⁷ , ⁸ Further, the women categorized the overall harm caused by the experienced issues. The harm levels were defined as follows: no harm, minimal harm (e.g., frustration or small bruise), minor harm (e.g., anxiety), moderate harm (e.g., infection or need of reoperation), major harm (medical side effect or posttraumatic stress disorder), and catastrophic harm (e.g., death, paralysis, or permanent injury). As the harm was reported overall per birth experience, it may reflect the cumulative impact of multiple problems rather than a single issue. Finally, the women were asked whether they had already filed a complaint or intended to. Eight months after distributing the questionnaire, we reviewed OUH's complaint database to identify if participants in the “consider” group had filed complaints. Those who had not were placed in the “no complaint” group, and those who had were placed in the “complaint” group. The women gave informed consent before participating in the study.

Data from questionnaires were kept in a REDCap database, a program approved for sensitive personal data. ⁹ , ¹⁰

2.3. Statistical Analysis

We used descriptive statistics to analyze the problem patterns of the described birth experiences in the survey, displaying the proportions of the HCAT categories. Participants could assign their birth experiences into multiple problem categories, resulting in more problems than experiences. To identify the extent of unreported negative birth experiences, we estimated the ratio of the dark figure of complaints. The dark figure ratio is defined as the number of unreported incidents of a given problem divided by the number of formally reported incidents of the same problem. A Poisson distribution was applied to estimate 95% confidence intervals. We estimated a ratio for each problem category and each level of harm reported in the survey. The dark figure ratios represent how frequently a problem occurs in a birth experience compared to how often it is formally complained about. All data management and analyses were done using Stata version 18. ¹¹

3. RESULTS

3.1. Characteristics of the survey respondents

We invited 3081 women, of whom 1022 (33.2%) responded and were included in the study. Among these women, 336 (32.9%) reported negative birth experiences relating to their birth in 2022 at OUH. In this study, 721 (70.5%) women were between 24 and 35 years of age, and 780 (76.3%) had an education of two or more years of higher education. There were no women below 18, and only a minority (25; 2.4%) of women had more than three births. The characteristics of the survey respondents are shown in Table 1.

TABLE 1.

Characteristics of survey respondents.

	Women with a negative birth experience N = 336 (100%)	Women with a positive birth experience N = 686 (100%)
Age at birth in 2022
<18	0 (0)	0 (0)
18–23	15 (4.5)	21 (3.1)
24–29	115 (34.2)	222 (32.4)
30–35	120 (35.7)	264 (38.5)
36–41	41 (12.2)	79 (11.5)
42–45	3 (0.9)	8 (1.2)
>45	1 (0.3)	0 (0)
No response	41 (12.2)	92 (13.4)
Education
Primary school	4 (1.2)	13 (1.9)
Vocational education	30 (8.9)	36 (5.2)
Upper secondary education	23 (6.8)	50 (7.3)
1–2 years of higher education	24 (7.1)	48 (7.0)
2–4½ years of higher education	132 (39.3)	300 (43.7)
5+ years of higher education	115 (34.2)	233 (34.0)
No response	8 (2.4)	6 (0.9)
Marital status
Living together/married	302 (89.9)	658 (95.9)
Single	30 (8.9)	25 (3.6)
No response	4 (1.2)	3 (0.4)
Number of births
1	220 (65.5)	293 (42.7)
2	85 (25.3)	293 (42.7)
3	27 (8.0)	79 (11.5)
4	2 (0.6)	21 (3.1)
5	1 (0.3)	0 (0.0)
>5	1 (0.3)	0 (0.0)
Contact with the health visitor a
No	22 (6.5)	53 (7.7)
Yes	313 (93.2)	629 (91.7)
No response	1 (0.3)	4 (0.6)
Considerations about filing a complaint of those who had a negative experience
Filed	26 (7.7)	Not applicable
Not filed	310 (92.3)	Not applicable

^a The women were asked the following question: “Have you been in contact with the health visitor following your childbirth in 2022?” A health visitor is a nurse with specialized education who is automatically offered to new parents after childbirth, providing guidance during the child's first year.

3.2. Characteristics of unreported negative birth experiences

Of the 336 women with negative experiences, 26 had filed a complaint. Thus, 310 women did not file a complaint regarding their negative birth experiences. Therefore, the further descriptive analysis was limited to these 310 women to ensure a problem pattern of only unfiled cases.

The 310 negative birth experiences comprised 787 problems distributed on the three HCAT domains and seven problem categories. Table 2 shows that the most common domain displayed in the questionnaire overall is the relationship domain, containing 336 (42.7%) problems. The two most common categories represented in the women's negative birth experiences are problems with communication, accounting for 155 (19.7%) problems, and problems with quality, accounting for 149 (18.9%) problems. The least described problem is respect and patient rights with 58 (7.4%) problems. The harm caused in this unfiled complaint sample is mainly none, minimal, or minor (10.3%, 31.6%, and 34.2%, respectively), characterized by, for example, frustration or anxiety. Only a minor amount of 20 (13.5%) women reported moderate to catastrophic harm (Table 3).

TABLE 2.

Patient perceived problems and related dark figures ratios of negative birth experiences.

HCAT domains and problem categories	Negative birth experiences not reported in complaints N (%)	Negative birth experiences reported in complaints N (%)	Dark figure ratio (CI)
Total number of problems	787 (100)	97 (100)
Clinical	251 (31.9)	31 (32.0)	8.1 (7.1–9.2)
Quality	149 (18.9)	18 (18.6)	8.3 (7–9.7)
Safety	102 (13.0)	13 (13.4)	7.8 (6.4–9.5)
Management	200 (25.4)	18 (18.6)	11.1 (9.6–12.8)
Environment	109 (13.9)	11 (11.3)	9.9 (8.1–12)
Institutional processes	91 (11.6)	7 (7.2)	13.0 (10.5–16)
Relationship	336 (42.7)	48 (49.5)	7.0 (6.3–7.8)
Listening	123 (15.6)	18 (18.6)	6.8 (5.7–8.2)
Communication	155 (19.7)	18 (18.6)	8.6 (7.3–10.1)
Respect and patient rights	58 (7.4)	12 (12.4)	4.8 (3.7–6.2)

Note: The populations used are the 310 women with 787 problems not complaint about, and the 26 women with 97 problems filed in complaints (respectively). The text and numbers marked in bold shows the three HCAT domains, whereas the text and numbers not marked in bold shows the seven underlying HCAT problem categories. The confidence intervals of the dark figure ratios are based on Poisson.

Abbreviations: HCAT, Healthcare Complaint Analysis Tool; N, number.

TABLE 3.

Patient harm and dark figures of harm.

Levels of harm	Negative birth experiences not reported in complaints N (%)	Negative birth experiences reported in complaints N (%)	Dark figure ratio (CI)
Total number of cases	310 (100)	26 (100)
No harm	32 (10.3)	0 (0)	… a
Minimal	98 (31.6)	5 (19.2)	19.6 (15.9–23.9)
Minor	106 (34.2)	5 (19.2)	21.2 (17.4–25.6)
Moderate	22 (7.1)	4 (15.4)	5.5 (3.4–8.3)
Major	19 (6.1)	4 (15.4)	4.8 (2.9–7.4)
Catastrophic	1 (0.3)	3 (11.5)	0.3 (0–1.9)
No information	32 (10.3)	5 (19.2)	6.4 (4.4–9.0)

Note: The confidence intervals of the dark figure ratios are based on Poisson.

Abbreviation: N, number.

^a No complaints were filed for cases with no harm, making a dark figure ratio calculation impossible.

3.3. Dark figure ratios

The highest dark figure ratios among the HCAT problem categories are within the management domain (11.1) (see Table 2), comprising the environment and institutional processes, with ratios of 9.9 and 13, respectively. The lowest ratio is 4.8, which pertains to respect and patient rights within the relationship domain, with an overall ratio of 7.0. In general, every problem category has a dark figure ratio above 1.0, indicating a notable extent of women not filing complaints despite experiencing problems.

Birth experiences resulting in minimal and minor harm have higher dark figure ratios (19.6 and 21.2, respectively) compared to moderate, major, and catastrophic harm (5.5, 4.8, and 0.3, respectively). This trend suggests that women are more likely to file complaints when experiencing a higher level of harm than when harm is minimal (see Table 3).

4. DISCUSSION

In this study, we aimed to identify the problem pattern of negative birth experiences at a university hospital that are not formally reported in complaints, and we estimated the dark figures of complaints at the maternity ward.

We found that 336 (32.9%) of the 1022 women in the survey had a negative birth experience, and 310 (92.3%) of these did not file a complaint. The most significant proportion of unreported problems in complaints concerns issues related to institutional processes (e.g., delay and cancellations) with a dark figure ratio of 13.0. This means that there were 13 additional unreported instances of similar problems for every complaint filed about institutional processes. Such a high ratio highlights a substantial gap between the frequency of negative experiences and the formal reporting of these issues in complaints, underscoring the potential underestimation of systemic problems in healthcare services when only looking at filed complaints. Communication issues were also a frequently reported problem, described by 155 (19.7%) women in the survey, but they are rarely included in complaints. The dark figure ratio for communication problems reveals that women at the maternity ward experience 8.6 times more communication issues than are reflected in filed complaints. However, these relational issues may be perceived as less harmful than problems within the clinical domain, potentially leading to underreporting despite their negative impact on patients' experience of healthcare services. This underreporting may be linked to the perception of low harm, as 236 (76.1%) women reported none to minor harm. The combination of high dark figure ratios and low perceived harm suggests the existence of a threshold of which women may not find it worthwhile to file a complaint.

Although the relationship domain accounts for a significant proportion of the problems, respect and patient rights represent only a small fraction. A similar pattern is observed in a study by Baranowska et al. of Polish maternity care, where 45% of women reported experiencing disrespect through staff communication, yet only 3% formally complained about rights violations. ¹² Similarly, Rudman and Waldenström found that women described the hospital staff as unfriendly and disrespectful and highlighted poor communication, mirroring the findings in the current study. ⁶ In alignment with the study of Baranowska et al., Rudman and Waldenström also found their study population abstaining from criticizing this care. ⁶

The present study showed a dark figure ratio for respect and patient rights of 4.8, indicating that some problems within this category are not complained about. However, this is the lowest dark figure ratio among all the HCAT categories, suggesting that the experiences related to respect and patient rights are more aligned with filed complaints than other issues. While the exact reason for this is unclear, patients may have a lower tolerance for disrespect, or they perceive the violation of respect and patient rights as more tangible and complaint‐worthy than other types of problems.

A previous Danish study by Walløe et al. investigated the complaint pattern for obstetric hospital care at hospitals in the Region of Southern Denmark, including Odense University Hospital. ³ The study highlighted notable differences between complaints regarding obstetric care and those concerning healthcare in other hospital areas. Complaints reported about obstetric care contained more relational issues, whereas complaints about other healthcare services were primarily related to clinical issues. ³ This finding aligns with the current results, where the relational domain was the most frequently described problem of women's birth experience. In contrast to the present survey's high proportion of low harm levels described in unreported experiences, the study by Walløe et al. shows a much lower proportion of low harm levels in the reported complaints regarding obstetric care. These findings emphasize the dark figure ratios regarding harm, indicating that several women with negative birth experiences related to minor harm do not formally complain, reflecting a ‘harm threshold’ for complaining. Furthermore, studies show that women's fears and attitudes, as well as a history of abuse prior childbirth, are associated with negative birth experiences. ¹³ , ¹⁴ This indicates that personal factors and expectations influence a woman's birth experience and may also affect whether they choose to file a complaint. Data on this matter were not accessed in this study. Regarding disappointments and unmet expectations, the birth plan has been considered a central measure. ¹⁵ Careful involvement of women and optimizing the birth plan to take into account the concerns of women giving birth may prove to prevent unmet expectations, disappointment and complaints in some cases.

A limitation of the present study is the relatively low response rate of 33.2% and the risk of selection bias, as the women with negative birth experiences might be overrepresented due to their greater need to share their stories. Another limitation of the study is that the analysis of the survey responses is based on the respondents' interpretation of the HCAT problem categories. The HCAT is designed to be used by trained coders, but in this study, the women themselves classified their birth experiences. To address this limitation, we provided examples of the seven HCAT problem categories in the questionnaire to assist the women in interpreting the categories. Additionally, a limitation arises due to the inability to link the problem categories with the level of harm caused, as the harm reflects the overall birth experience rather than a single issue. Therefore, it should not be concluded that communication issues are rarely reported because they cause minimal harm, as the underlying reasons may be more complex. Further, the generalizability of this study is limited to birth experiences only. The findings probably cannot be generalized to other contexts of patient experiences, such as other wards at the hospital. Women in labor are hospitalized for reasons different from those of typical patients and may have other expectations of the care provided and therefore, a different perspective on their experience. To capture a broader range of patient experiences, further studies involving patients from other wards are needed. The present study did not analyze the women's resourcefulness. However, it would be valuable to include this in further studies to identify potential inequality in patient experiences and thresholds for filing complaints.

A strength of the study is that the questionnaire is based on the validated HCAT taxonomy, which is also used for categorizing filed complaints. This enables reliable insights into the underestimation of specific problem categories, as the dark figure ratios are solidly based on a consistent categorization used for both the survey responses and filed complaints. Another strength is how we distributed the questionnaire to the women. This was done through their electronic mailbox, the most widely used digital access to citizens in Denmark, ¹⁶ ensuring that we reached a substantial number of women. Further, we distributed the questionnaire only 1–2 years after the women's childbirths, substantiating that the women would still remember their birth experiences.

5. CONCLUSION

In this questionnaire study using women's birth experiences at a maternity ward, we found that negative birth experiences are often characterized by relational issues, such as poor communication as well as problems with quality of care. We estimated the dark figures of negative birth experiences not complained about and found that a dark figure exists within every problem category with varying dark figure ratios between 4.8 and 13.0, revealing a substantial underestimation regardless of the problem. The variation of ratios across problem categories as well as harm levels, indicate different thresholds for complaining according to the problem and harm experienced. To our knowledge, this is the first study to describe the dark figures of complaints, thus revealing novel insights into patient experiences not reported in complaints. This knowledge is essential for identifying the actual pattern and frequency of negative experiences, as well as for developing interventions informed by patient experiences.

AUTHOR CONTRIBUTIONS

Study preparation and planning: MKC, SBB, SFB, and LM. Data collection: MKC. Data processing: MKC and SBB. Analysis: MKC and SBB. Manuscript read and work through: MKC, SBB, SFB, and LM. AI was used for supporting the English writing.

FUNDING INFORMATION

None required.

CONFLICT OF INTEREST STATEMENT

None.

ETHICS STATEMENT

According to Danish law, the processing of personal data must comply with general data protection regulations (Directive 95/46/EC; 2016/679 and DK Act 502). Permission to store and analyze data was given by the Region of Southern Denmark (23/10902). The execution of the survey required legal authorization due to the Danish Health Care Act Para 46 so that we could get access to the women's medical records and, thereby, their unique person identification numbers, so we had the opportunity to invite them via their electronic mailbox. ¹⁷ The legal authorization granted access to the women's medical records exclusively to retrieve identification numbers, but not for extracting clinical or medical information. The Region of Southern Denmark approved our application for access to the women's medical records on October 27, 2023 (23/10824). Furthermore, the Danish Healthcare Act Para 46 required permission from the attending midwife or head of department before reaching out to the women. ¹⁷ On the November 7, 2023, we got permission from the head of department to reach out to the women.

Clausen MK, Bogh SB, Birkeland SF, Morsø L. Pattern of unreported negative birth experiences in the maternity ward. Acta Obstet Gynecol Scand. 2025;104:1759‐1765. doi: 10.1111/aogs.70008

DATA AVAILABILITY STATEMENT

Research data are not shared.