Obstetrics Initiative COMFORT notably increases safer prescribing after childbirth

The Obstetrics Initiative, a Collaborative Quality Initiative dedicated to improving childbirth care in Michigan, works with more than 70 hospital teams to help maternity clinicians improve postpartum pain control, reduce harmful opioid prescribing and promote more equitable, respectful care.

Prescribing opioids after childbirth is excessive, risky and variable. According to national data, 1 in 75 people who are exposed to opioids during their postpartum recovery will develop a new, persistent opioid use disorder. In addition, there are wide variations in prescribing opioids postpartum across Michigan, with hospital averages ranging from 32% to 100% of patients receiving an opioid prescription after childbirth. With these statistics in mind, the Obstetrics Initiative, or OBI, team has developed a new pain management plan focused on reducing opioid use postpartum, resulting in a dramatic reduction in prescribing opioids postpartum.

Creating COMFORT

OBI, in partnership with several national societies, developed and launched the COMFORT initiative,* or Creating Optimal pain Management FOR Tailoring interventions after childbirth, in mid-2023 with a toolkit of recommendations from a national panel of experts to support specific protocols in response to the overwhelming problems with postpartum opioid prescribing. The COMFORT initiative is already being widely adopted by OBI hospitals, and compliance in scheduling non-opioid treatment for eligible cesarean patients (with nulliparous, term, singleton, vertex births) rose from 76.2% in January 2024 to 96.2% in December 2024.

The COMFORT clinical practice guidelines aim to promote more respectful, equitable postpartum pain management through care that is both evidence-based and tailored to individual risk factors, preferences and values. COMFORT recommendations for prescribers include:

• Providing robust education and counseling about pain management and the risks of opioid prescribing
• Using scheduled non-opioid medications (acetaminophen and NSAIDs) as the first choice for postpartum pain
• Offering non-pharmacologic strategies (for example, heat or ice, abdominal binder, aromatherapy) to augment pain management after birth
• Considering inpatient strategies, particularly for patients with more complex postpartum pain or who are unable to receive standard treatments
• Considering tailored opioid prescribing through a shared decision-making process
• Using a principles-based approach to postpartum pain management for patients with opioid use disorder, chronic pain and other complex pain

OBI collects two sets of data points around COMFORT: the rate of opioid prescribing postpartum, and scheduled NSAID and acetaminophen. An OBI-led facilitation process was also launched in October 2024 to continue to improve both areas of care delivery.

COMFORT at work

As COMFORT clinical practice guidelines have rolled out to Michigan practitioners, feedback has been positive, and as one nurse points out, eye-opening to care standards: “As a nurse with over 20 years of experience and a strong advocate for high-quality care, I’ve always sought to protect my team from unnecessary workflow changes. One COMFORT measure I hesitated to implement was scheduled Motrin and Tylenol after birth, believing PRN (such as, as needed) orders were more efficient on vaginal deliveries. That changed when I watched my own daughter give birth and struggle to advocate for herself in managing her pain. Seeing firsthand how scheduled order sets empower patients to receive timely care without having to ask was eye-opening. This experience reinforced that COMFORT protocols truly prioritize the patient experience. I am confident that the Obstetrics Initiative and our birthing center are providing a progressive evidence-based approach to managing our patients' postpartum pain for all births.”

OBI will continue its work with COMFORT in 2025, with a goal that by December more than 70% of OBI-affiliated hospitals in Michigan will offer COMFORT Clinical Practice Guideline-concordant care for all deliveries — cesarean or vaginal births. (This will be measured by getting more than 70% of clinicians trained on COMFORT guidelines and more than 90% of eligible patients receiving opioid-sparing postpartum pain management.)

For more information

• Additional resources – including the COMFORT tool – can be found on the OBI website.*
• To learn about the Collaborative Quality Initiatives, visit cqis.org.*

*Blue Cross Blue Shield of Michigan doesn’t own or control this website.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.