Caring for women both near and far

Going beyond primary care

One area that is poised for growth is care for women with high-risk pregnancies, called maternal-fetal medicine. This includes mothers with chronic hypertension, diabetes, or thyroid disease, any of which may negatively affect the pregnancy, as well as anomalies detected in the baby. The good news is that the science to intervene in these cases is moving fast.

“Advances in technology have given us the ability to do things we could not do just ten years ago,” says Tuuli. In the field of genetics, for example, the test for Down syndrome used to be an amniocentesis (fluid drawn from around the baby), which carries a risk of miscarriage. Now, says Tuuli, we can use cell-free, fetal DNA testing, which requires a simple test of the mother’s blood. In the lab, they can isolate pieces of the baby's DNA and tell, to a high degree, the likelihood of an anomaly.

Another advance in fetal care is that many conditions that affect the baby can now be diagnosed with ultrasound technology, and, if surgery is necessary, it can sometimes be performed in utero. With some conditions such as spina bifida, the neurological outcomes are much better if surgery is done before the baby is delivered.

Brown and Women & Infants Hospital also participate in the Maternal-Fetal Medicine Units Network — a group of academic hospitals across the United States, 12 of which (including Brown) have been selected by the National Institutes of Health because of their focus on obstetric research. “We count ourselves very lucky to be part of this select group at the forefront of answering really critical questions that go on to change practice” says Tuuli. “Many of the trials that have been done within this network have changed how we take care of pregnant women and newborns.”

Keeping an eye on inequities

With all of these advances, says Tuuli, there are still many challenges, and health care disparities are foremost among them.

“Equal access to quality care is our goal, but I will say it's a goal that is not fully realized,” says Tuuli. There are several reasons for that. For some women, living conditions make it difficult for them to capitalize on care. For others, it could be insurance-related, or transportation, or mistrust for the health care system. Without improving those situations within the community, says Tuuli, patients may delay care, which can increase the chance of complications.

Tuuli notes that Brown and Women & Infants Hospital take equity very seriously. “We break down outcomes of our patients by race and ethnicity, and we have started targeted programs to tackle some of these complications that seem to be disparate between our patient populations. For example, we're having conversations around community health workers who may be able to go to the homes of the most vulnerable of our patients and check their blood pressures and check on them and connect them back to the health care system.”

Tuuli knows that achieving equity is critical and complex. “If these things were easy, somebody would have solved them by now,” he says. But he also says that this generation of trainees and junior faculty are “very conscious of these disparities and are committed to making progress. And I believe we will.”

There are some tangible outcomes clinicians can measure, such as what proportion of Black babies die within the first month of birth versus others; or how many Black women develop complications from preeclampsia as compared to other racial groups. Providers can also measure patient experience and divide those experiences by race and ethnicity. This way, says Tuuli, they can see what Black patients are saying about their care experience, which is not always the same in terms of quality.

To achieve equity, there also must be a workforce where providers look like the communities they serve.

“There is data to suggest that patients who are cared for by physicians and providers of their same race and ethnicity tend to have better outcomes,” says Tuuli.

All Brown and Women & Infants Hospital trainees, physicians, and nurses receive diversity training to understand the basis of unconscious bias and the role it can play in health care, but there is additional value in a provider’s ability to relate to their patients culturally. It allows them to build trust, says Tuuli, and that can result in patients being more compliant with things like taking medication, which translates into better health outcomes.

“I think this multifaceted approach — both at the point of taking care of patients, where we ensure and take conscious efforts to be equitable, as well as developing our workforce — is the way we can get to a place where our providers, our physicians, our nurses reflect the community that we serve,” says Tuuli. “I think that will be an important component in achieving equitable care for our patients.”

Advocating for women, from clinics to Congress

Another element that sets Brown apart from other institutions is the inclusion of reproductive health training as part of the curriculum for the next generation of health practitioners. This is critical, says Tuuli, because nationally, there is an attack on women's health.

“There are laws in many states which aim to limit the choices that women are able to make about their own bodies, whether it's about contraception or abortion care and other reproductive health care,” says Tuuli. “The other role that we play as women’s health physicians is as advocates for our patients, because there is no other medical specialty whose primary focus is women.”

Brown faculty and trainees advocate to the Rhode Island General Assembly and travel to Washington D.C. to advocate directly to Congress about supporting reproductive health care. This advocacy led to the passage of a bill in Rhode Island which requires health insurance companies to cover the cost of having the support of a doula during delivery.

There are also reproductive health electives in the Medical School, and efforts like the Sexual Health Advocacy and Policy Education (SHAPE) program, which offers pilot grants to medical students to encourage curricular innovation in the areas of reproductive and sexual health policy analysis and advocacy.

Applying a global perspective

As chair of OB/GYN, Tuuli plans to focus his attention on patient care, education, research, and advocacy, and he thinks Brown’s program is primed to be a center of excellence in women's health research. Brown’s research agenda in this area is comprehensive, ranging from fundamental science to translational research, clinical research, and public health.

From a research standpoint, Tuuli says that his work in the U.S. and globally have now merged, and that offers great advantages. With programs at Women & Infants Hospital, multicenter trials across the country, and a large research team in Ghana funded by the Gates Foundation, he is able to ask broad questions and get useful data in return.

Why do some women in developing countries have good birth outcomes and some do not? How do we best take care of patients in the U.S. who have anemia in pregnancy? How can we reduce C-sections safely? And, how can we ensure that all our patient populations have similar high-quality care and outcomes as well as experiences?

“That feedback loop — asking related, sometimes different, questions that complement each other — is an exciting part of my career,” says Tuuli, “It helps us tackle very serious problems.” This global perspective, he says, can also help leverage all the insights that Brown has gained and move health care forward for all women and children.

“If the COVID-19 pandemic has taught us anything,” says Tuuli, “it is that the world is truly a global village. And somebody who sneezes in a small village in Ghana can result in someone developing COVID pneumonia and being admitted to the ICU in Providence.”

A patient-centered focus

When asked what brought him to women’s health as a career, Tuuli said coming from a very poor community in Northern Ghana, his reasons were simple and from the heart. “I have four sisters; I have my mom; and growing up, I saw the challenges they faced in receiving quality care.” He also said that women are typically great patients.

“In my experience, if you provide health care to a man, you provide health care to an individual. But if you take good care of a woman, you are indeed taking care of an entire family, an entire village, and an entire nation. So, once I decided to do women's health, I've never looked back. I can't imagine doing anything different.”

After earning his medical degree from the University of Ghana Medical School, Tuuli completed a Master’s in Public Health at the University of California, Berkeley and a residency in obstetrics and gynecology at Emory University, followed by a subspecialty fellowship in maternal-fetal medicine at Washington University in St. Louis.. He recently completed a Master’s in Business Administration focusing on the Business of Medicine at the Kelley School of Business at Indiana University.