DoulaCare Hawai’i                         The Barefoot Doctors’ Academy                                                                                     P.O. Box 371; Hawi, Hawai’i  96719                                                                             Phone: (808)889-1922

             EVALUATION OF LABOR SUPPORT SERVICES

        Mother's Name:___________________________________________________________________________

Baby’s Date of Birth:______________________________________________________________________

Hospital or Birth Location, (including city and state):__________________________________________

Doula’s Name:____________________________________________________________________________

The Barefoot Doctors’ Academy would appreciate your taking a moment to evaluate your perception                                                                          of the doula's role.  Please circle the number which most closely reflects your opinion of her contribution.

                                                                                                                                           More harm than good------Neither helped nor hurt------Was a big help

1. Were the techniques suggested by the doula helpful to the mother in handling the physical aspects of her labor?	1	2	3	4	5
2. Were the techniques used by the doula helpful to the mother in handling the emotional aspects of her labor?	1	2	3	4	5
3. Were the suggestions of the doula helpful for the father and/or other family members and friends present for the labor?	1	2	3	4	5
4. Overall, how would you evaluate the usefulness of having the doula present?	1	2	3	4	5
5. Do you have any other comments or suggestions?

 6. What was your role?      􀀀 Baby’s mother       􀀀 Father/Partner       􀀀 Other family        􀀀 Friend

     􀀀 Doctor       􀀀 Certified Nurse Midwife        􀀀 Direct Entry Midwife       􀀀 Nurse      􀀀 Other staff   

7.  If you are not the mother, how long were you with the mother in labor? (approximately) _____ hours

                                                                                               _____Continuously?         _____Off & on?

Your Name (optional): _____________________________________

Thank you very much for taking the time to complete this evaluation.  Please return it to the doula so that                                                                she may use it for certification purposes.  If you have further comments or questions,                                                                                             feel free to contact us at the address printed on above letterhead.  

Doula’s address________________________________________________________________________