. 2025 Jan 2;6(1):1.

doi: 10.1186/s43058-024-00687-5.

Development of an implementation intervention to promote adoption of the COMFORT clinical practice guideline for peripartum pain management: a qualitative study

Limi Sharif¹, Shelytia Cocroft², Shawna N Smith^{3

4

5

6}, Christopher Benincasa⁷, Alex F Peahl^{2

5

6}, Lisa Kane Low^{2

5

6

8}, Jennifer Waljee^{9

10

11}, Carrie Miller^{2

5}, Carey Simpson^{2

5}, Michelle H Moniz^{12

13

14}

Affiliations

¹ Department of Anesthesiology, University of Michigan, Ann Arbor, USA.
² Department of Obstetrics and Gynecology, University of Michigan, 2800 Plymouth Rd., Building #10, Rm G016, Ann Arbor, MI, 48109-5276, USA.
³ Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, USA.
⁴ Department of Psychiatry, University of Michigan, Ann Arbor, USA.
⁵ Obstetrics Initiative, Ann Arbor, USA.
⁶ University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, USA.
⁷ Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA.
⁸ University of Michigan School of Nursing, Ann Arbor, USA.
⁹ Center for Healthcare Outcomes and Policy (CHOP), Ann Arbor, USA.
¹⁰ Michigan Opioid Prescribing Network, Ann Arbor, USA.
¹¹ Department of Surgery, University of Michigan, Ann Arbor, USA.
¹² Department of Obstetrics and Gynecology, University of Michigan, 2800 Plymouth Rd., Building #10, Rm G016, Ann Arbor, MI, 48109-5276, USA. mmoniz@med.umich.edu.
¹³ Obstetrics Initiative, Ann Arbor, USA. mmoniz@med.umich.edu.
¹⁴ University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, USA. mmoniz@med.umich.edu.

PMID: 39748382
PMCID: PMC11697899
DOI: 10.1186/s43058-024-00687-5

Development of an implementation intervention to promote adoption of the COMFORT clinical practice guideline for peripartum pain management: a qualitative study

Limi Sharif et al. Implement Sci Commun. 2025.

. 2025 Jan 2;6(1):1.

doi: 10.1186/s43058-024-00687-5.

Authors

Affiliations

¹ Department of Anesthesiology, University of Michigan, Ann Arbor, USA.
² Department of Obstetrics and Gynecology, University of Michigan, 2800 Plymouth Rd., Building #10, Rm G016, Ann Arbor, MI, 48109-5276, USA.
³ Department of Health Management & Policy, School of Public Health, University of Michigan, Ann Arbor, USA.
⁴ Department of Psychiatry, University of Michigan, Ann Arbor, USA.
⁵ Obstetrics Initiative, Ann Arbor, USA.
⁶ University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, USA.
⁷ Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA.
⁸ University of Michigan School of Nursing, Ann Arbor, USA.
⁹ Center for Healthcare Outcomes and Policy (CHOP), Ann Arbor, USA.
¹⁰ Michigan Opioid Prescribing Network, Ann Arbor, USA.
¹¹ Department of Surgery, University of Michigan, Ann Arbor, USA.
¹² Department of Obstetrics and Gynecology, University of Michigan, 2800 Plymouth Rd., Building #10, Rm G016, Ann Arbor, MI, 48109-5276, USA. mmoniz@med.umich.edu.
¹³ Obstetrics Initiative, Ann Arbor, USA. mmoniz@med.umich.edu.
¹⁴ University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, USA. mmoniz@med.umich.edu.

PMID: 39748382
PMCID: PMC11697899
DOI: 10.1186/s43058-024-00687-5

Abstract

Background: Pain management after childbirth is widely variable, increasing risk of untreated pain, opioid harms, and inequitable experiences of care. The Creating Optimal Pain Management FOR Tailoring Care (COMFORT) clinical practice guideline (CPG) seeks to promote evidence-based, equitable acute peripartum pain management in the United States. We aimed to identify contextual conditions (i.e., barriers and facilitators) and discrete implementation strategies (i.e., theory-based actions taken to routinize a clinical practice) likely to influence COMFORT CPG uptake and specify corresponding multi-component implementation interventions at the perinatal quality collaborative- and unit-level.

Methods: We conducted a qualitative study involving virtual individual interviews and focus groups. Interviews included individuals undergoing childbirth from 2018-2023, (recruited through two online registries), and actively practicing maternity clinicians and surgeons, (recruited via snowball sampling with the eDelphi panel creating the COMFORT CPG), caring for pregnant people in the United States. Focus groups included physicians, midwives, nurses, and unit-based quality improvement (QI) staff working at Michigan hospitals within the Obstetrics Initiative, a statewide perinatal quality collaborative funded by Blue Cross Blue Shield of Michigan and Blue Care Network. The Consolidated Framework for Implementation Research, Expert Recommendations for Implementing Change taxonomy, and Replicating Effective Programs framework informed data collection and analysis. Qualitative content analysis characterized influential contextual conditions, which were linked to implementation strategies and tools using principles of implementation mapping. We then specified multi-component implementation interventions for use by quality collaboratives and unit-based teams.

Results: From May-September 2023, we completed 57 semi-structured individual interviews (31 patients, 26 clinicians) and six focus groups (44 QI champions). Participants identified 10 key conditions influential for COMFORT CPG adoption. Findings enabled identification of five collaborative-level implementation strategies, 27 unit-level implementation strategies, and 12 associated tools to promote COMFORT CPG adoption including the specification of each strategy's hypothesized mechanism of action and each tool's goal and potential uses.

Conclusions: This work identifies contextual conditions and implementation strategies and tools at the perinatal quality collaborative and unit levels to promote COMFORT CPG adoption on maternity units. These findings may foster more rapid CPG implementation and thereby promote more equitable and evidence-based perinatal pain management care.

Keywords: CFIR; E-REP; ERIC; Guideline; Implementation; Intervention; Maternity care; Pain; Peripartum.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study was approved by the University of Michigan Institutional Review Board. Consent for publication: Not applicable. Competing interests: MHM receives grant funding from the Food and Drug Administration, the National Institute for Child Health and Human Development, and Michigan Department of Health and Human Services, and salary support from Blue Cross Blue Shield of Michigan (for directing OBI). SS, AFP, LKL, and CM also receive salary support from Blue Cross Blue Shield of Michigan as core faculty and staff for OBI. AFP receives grant funding from the National Institutes of Health, Michigan Department of Health and Human Services, and the Michigan Health Endowment Fund, research support from Pulsenmore, and is a consultant for Mirvie. The remaining declare that they have no competing interests.

Figures

**Fig. 1**
Flowchart of Methods and Deliverables

See this image and copyright information in PMC

Cited by

Can theory-driven implementation interventions help clinician champions promote opioid stewardship after childbirth? Protocol for a pragmatic implementation study.
Moniz MH, Kilbourne AM, Peahl AF, Waljee JF, Cocroft S, Simpson C, Kane Low L, Bicket MC, Englesbe MJ, Stout MJ, Gunaseelan V, Bourdeau A, Hu M, Miller C, Smith SN. Moniz MH, et al. Front Glob Womens Health. 2025 Mar 14;6:1504511. doi: 10.3389/fgwh.2025.1504511. eCollection 2025. Front Glob Womens Health. 2025. PMID: 40160195 Free PMC article.

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Development of an implementation intervention to promote adoption of the COMFORT clinical practice guideline for peripartum pain management: a qualitative study

Affiliations

Development of an implementation intervention to promote adoption of the COMFORT clinical practice guideline for peripartum pain management: a qualitative study

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Abstract

Conflict of interest statement

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