COMMUNITY MIDWIVES OF BRANTFORD
Intake Form
About Us
Our Midwives
Birth Stories
Location
Contact
Student Evaluation
What is Midwifery?
Pregnancy
Pregnancy Care for Clients
When to Call your Midwife
Working with Students
Pregnancy Resources
Booklist
Crisis Lines
Birth
Home and Hospital Birth
Midwifery Care During Birth
Preparing for Birth
Postpartum
Care for Clients After Birth
Care for the Newborn
When to Call Your Midwife
Breastfeeding
Leaving Midwifery Care
Midwifery Care Evaluation Form
CLIENT EVALUATION OF MIDWIFERY CARE
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
*
Indicates required field
When did you have your baby?
*
January
February
March
April
May
June
July
August
September
October
November
December
Year
*
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
Other
*
2. What factors influenced you to choose midwifery care? Check all that apply.
*
Extra support
Continuity of care
Pregnancy & child birth as a normal event
Assistance with breast feeding
Other
Other
*
3. Your age. Choose One:
*
Under 15
15-19
20-29
30-39
40+
4. Was this your first birth?
*
Yes
No
5. Was this your first birth with a midwife?
*
Yes
No
Prenatal Care
Please rate the following aspects of your prenatal care.
6. The length of your prenatal visits:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
7. Usefulness of information provided for decision making:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
8. Accessibility/availability of your midwife:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
9. Your confidence in her skills and abilities:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
10. How comfortable you felt asking questions:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
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.
11. Accessibility/availability of your midwife during labour:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
12. Your confidence in her skills and abilities:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
13. Usefulness of information provided for decision-making:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
14. Adequately informed about the choices of birth place:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
15. Where was your baby born?
*
Home
Brantford General Hospital
Other
Other
*
16. If delivered in hospital did you go home within 4 hours?
*
Yes
No
17 Was this where you planned to give birth?
*
Yes
No
18. Was there a second midwife at the birth?
*
Yes
No
18a. If yes had you previously met her?
*
Yes
No
18b. Were you comfortable with her involvement?
*
Yes
No
Comments or suggestions for improvements to labour and birth care:
*
Post-Birth Care
Please rate the following aspects of your post-birth care.
19. The number of visits from your midwife after the birth:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
20. The length of visits after your birth:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
21. The timing of visits after your birth:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
22. Availability/accessibility of your midwife:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
23. Usefulness of information provided about your care:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
24. Usefulness of information about care of your baby:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
25. How comfortable you felt calling with questions/problems:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
26. Your confidence in her skills and abilities:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
27. Your confidence in her skills and abilities:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
28. The support you received from your midwife after the birth:
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Any comments or suggestions:
*
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
Any additional comments:
*
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.
35. Did you receive enough information to make informed decisions?
*
Yes
No
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
Any additional comments:
*
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
38b. If yes, were you comfortable with her involvement?
*
Yes
No
39. Was a student involved in your labour and birth?
*
Yes
No
39b. If yes, were you comfortable with her involvement?
*
Yes
No
40. Was a student involved in your care following the birth?
*
Yes
No
40b. If yes, were you comfortable with her involvement?
*
Yes
No
Any additional comments:
*
Office: Staff and Location
Please rate your experience with our office staff and location.
How were you treated by our office staff when you:
41a. Contacted the clinic?
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
41b. Needed to contact your midwife?
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
41c. Requested literature or information
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
41d. Booked your appointments?
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
How would you rate the characteristics of the office staff:
42a. Polite
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
42b. Pleasant and courteous
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
42c. Helpful
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
42c. Professional
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
How would you rate the Practice Office:
43a. Comfort of the office?
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
43b. Location of the office
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
43c. Access to the office
*
Very Satisfied
Satisfied
Neutral
Unsatisfied
Very Unsatisfied
Any comments or suggestions:
*
Optional Information
We keep all feedback confidential, but if you wish to remain anonymous, please feel free to leave the following questions blank.
Your Name
*
First
Last
Email
*
Thank You
The Community Midwives of Brantford
Submit
Intake Form
About Us
Our Midwives
Birth Stories
Location
Contact
Student Evaluation
What is Midwifery?
Pregnancy
Pregnancy Care for Clients
When to Call your Midwife
Working with Students
Pregnancy Resources
Booklist
Crisis Lines
Birth
Home and Hospital Birth
Midwifery Care During Birth
Preparing for Birth
Postpartum
Care for Clients After Birth
Care for the Newborn
When to Call Your Midwife
Breastfeeding
Leaving Midwifery Care
Midwifery Care Evaluation Form