Midwifery Care Evaluation Form

Please take some time to provide us with your evaluation of the
midwifery care that you received during your recent pregnancy, birth and
postpartum period.
Please complete the form below.

Basic Information

1. How did you hear about Community Midwives of Brantford? Check all that apply. *

Friend/family member Doctor Health professional (nurse, chiropractor, massage therapist, etc.) Other

2. What factors influenced you to choose midwifery care? Check all that apply. *

Please rate the following aspects of your prenatal care.

Please use the space below to make any additional comments/suggestions for improvement to care. Your comments may assist us to improve the care we provide. *

Labour and Birth Care

Please rate the following aspects of your labour and birth care.

Please rate the following aspects of your post-birth care.

Continuity of Care

Midwives are required to provide “ Continuity of Care” to their clients. This is defined as 24-hour on-call
availability of one of the group of midwives known to the client throughout the course of care. Please
comment on your experience of the arrangements made by the practice group to provide this care.

29. Was it clear to you which midwife was primarily responsible for your care? *

Yes No

30. Were you satisfied with the opportunities you had to meet the other midwife/midwives involved in your care? *

Yes No

31. Were the practice’s arrangements for on-call availability made clear? *

Yes No

Please comment on your satisfaction with the practice arrangements for provisions of continuity of care: *

Scope of Practice

The midwifery scope of practice includes the provisions of care during normal pregnancy and normal
vaginal delivery. In some cases complications arise during pregnancy, birth or in the postpartum period
which require consultation with, and sometimes transfer of care to, another health care provider (i.e.
obstetrician, pediatrician). Please comment on the following aspects of your care regarding this issue.

32. Were you clearly informed regarding the midwife’s scope of practice? *

Yes No

33. If your care involved a consultation with another health care provider were you informed of the reasons for this consultation and the process? *

Yes No N/A

34. If your care involved a transfer of care to another health care provider were you informed of the reasons for this transfer and the process? *

Yes No N/A

Philosophy of Midwifery Care in Ontario

The “Philosophy of Midwifery Care in Ontario” recognizes the childbearing woman as the primary
decision-maker in her own care. Please comment on your experience of receiving information and
making decisions while in midwifery care.

36. Did you receive adequate/useful information regarding choice of birthplace? *

Yes No

37. In general, were your choices and decisions supported by your midwife? *

Yes No

Student Involvement

If a student was involved with your care, please answer the following.

38. Were you approached to have a student midwife involved in your care? *

Yes No

Office: Staff and Location

Please rate your experience with our office staff and location.

How were you treated by our office staff when you:

How would you rate the characteristics of the office staff:

How would you rate the Practice Office:

Optional Information

We keep all feedback confidential, but if you wish to remain anonymous, please feel free to leave the following questions blank.

CLIENT EVALUATION OF MIDWIFERY CARE