Quality of Care Client Evaluation Form

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We are interested in your feedback about the care you received. Your comments will be reviewed and can help us improve the quality of care we provide. We will directly respond to concerns if requested.

Name of your Midwife

Informed Choice- One of the guides of midwifery care is to provide clients with informed choice. The following questions help us ensure we are meeting that need or help us to improve.

Do you feel that the choices given throughout your pregnancy, birth and postpartum reflected the needs of you and your family?

Not at all

Absolutely yes

Clear selection

Did you feel like the decisions you made in your pregnancy, birth and postpartum were supported by your team of midwives without pressure or judgement?

Not at all

Absolutely yes

Clear selection

Do you feel like the frequency and length of pregnancy and post partum visits were suited to your personal needs for questions and understanding?

Not at all

Absolutely yes

Clear selection

Did you feel well supported during labour and receive the necessary information to make decisions?

Not at all

Absolutely yes

Clear selection

Please share more about your experience of informed choice and/or your thoughts for improvement

Communications- We would like to know how our systems of communication worked for you

Were you able to reach your midwife in a timely way for urgent situations?

Not at all

Absolutely yes

Clear selection

If consultants (obstetrician, paediatrician, anaesthetist etc) were involved in your care, did you understand why?

Did you find our administrative team to be welcoming and helpful?

Not at all

Absolutely yes

Clear selection

Accessibility- We strive to create a space where everyone feels welcome to receive midwifery care. The following questions are designed to reflect on how we can best meet the needs of our communities. We are aware there can be barriers to care for those who identify with being/having; no insurance, a different first language, low/no access to transportation, BIPOC, 2SLGBTQIA, a single parent, a refugee, a disability, a newcomer.

We try to share a variety of learning materials (binder, handouts, library, website, prenatal classes) to ensure accessible information is available. Did the learning materials meet your needs?

Not at all

Absolutely yes

Clear selection

Were your individual needs respected in your care planning, and consideration given to any barriers you experience?

Not at all

Absolutely yes

Clear selection

Please share any suggestions you may have to help us accommodate better in the future

At any point in your care did you experience discrimination related to midwifery services, including care at any site? (Hospital, lab, consultant, etc).

Yes

If 'yes' to the above, to ensure safety in disclosure, we would like to know more and offer a resolution process. Who would you like to follow up with?

No one at this time

Administrator (if you have a preference, write their name in the "Other" section)

Midwife (if you have a preference, write their name in the "Other" section)

Member of Countryside's DEIA committee (Discrimination, Equity, Inclusivity, Accessibility)

Other:

Summary- Thank you for choosing Countryside Midwifery services! Please feel free to add your name or leave blank. You may also indicate if you would like any follow up discussion regarding your care.

Please check if you would like a follow up discussion with..

Administrator (if you have a preference, write their name in the "Other" section)

Midwife (if you have a preference, write their name in the "Other" section)

Other:

Final comments?

If you have requested a follow up conversation, please provide us your contact information (phone number or email address).

Your Name: (if you wish to disclose, or you may remain anonymous)

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