We know the stats. But what are we doing to improve women’s health?
Growing up in northern Ghana, Methodius Tuuli, MD, MPH, MBA, knew of too many women who suffered from pregnancy complications, and too many newborn babies who died. He saw the challenges his own mother and his four sisters faced trying to get good medical care. The experiences propelled him to the University of Ghana Medical School and a career in obstetrics and gynecology.
When Tuuli left his home country for Atlanta in 2004, to begin his residency at Emory University, he thought he was also leaving behind distressingly high maternal and fetal mortality rates. “I thought, oh, these are developing country problems,” Tuuli says. “And you come to the US, and some days I’m reminded that this looks like what it was in Ghana.”
Women & Infants Hospital, where Tuuli is chief of obstetrics and gynecology, is by far the largest obstetrical facility in Rhode Island; about 80 percent of babies in the state are born there, and the patient population reflects that diversity.
Unfortunately the Ocean State also mirrors nationwide rates of poor maternal and infant outcomes—not as high as Ghana’s, to be sure, but significantly higher than peer countries like Japan, Australia, New Zealand, and most of Europe.
“Although the US is a developed country, our outcomes, in terms of maternal morbidity and mortality, are near third-world-country level,” says Tuuli, who is the Chace-Joukowsky Professor and Chair of Obstetrics and Gynecology. “And part of the reason is that we have disparities in outcomes, with Black and brown patients having much worse outcomes than our white patients.”
In Rhode Island, fortunately, the number of pregnancy-related deaths each year is too low to identify trends by race and ethnicity. However, other differences are clear: for example, while in 2020 the state had an overall infant mortality rate of 4.2 per 1,000 live births, according to the 2022 Rhode Island KIDS COUNT Factbook, 9.8 Black babies out of 1,000 died before their first birthday. That’s more than three times the rate that white infants died, and nearly twice the rate of Hispanic infant deaths. Rates of preterm births and low birthweight also show significant racial and ethnic disparities, and patients of color are more likely to receive delayed prenatal care than are white patients.
Several years ago, Women & Infants, in partnership with Brown’s Department of Obstetrics and Gynecology, began taking steps to address these inequities. From implicit bias training for all staff, to courses on racism in the residency curriculum, to a specific focus on social determinants of health in all case reviews, to a concerted effort to build a more diverse workforce, the changes have been sweeping, touching every employee and every aspect of ob/gyn care. Substantially improved patient outcomes, however, are only just starting to materialize—as Tuuli readily admits.
“The hospital and health system leaders are committed to this work,” he says. “It’s difficult, and some of these interventions won’t work. If it were easy, people would have done it already, right? … I’m just glad that we are starting.”
Founded in 1884 as the Providence Lying-In Hospital, Women & Infants has expanded far beyond its original, exclusive purpose as a facility for labor and delivery. While obstetric care remains its bread and butter, providers there treat patients from puberty through menopause. The hospital has strong programs in pelvic floor medicine, oncology, and reconstructive surgery. Patients can see reproductive endocrinologists and infertility specialists, and receive care for high-risk pregnancies and psychiatric conditions. There’s a busy emergency department and the only newborn intensive care unit in the region.
Less visible to the general public, but underpinning all of this clinical work, is a robust research program, a partnership with Brown and the Medical School. “There is a blossoming research portfolio,” Tuuli says. They are members of exclusive groups of academic research centers like the National Institute of Child Health and Human Development’s Pelvic Floor Disorders Network, Neonatal Research Network, National Cancer Institute-funded NRG Oncology, and Maternal-Fetal Medicine Units Network.
“We count ourselves very lucky to be part of this select group at the forefront of answering y critical questions that go on to change practice,” Tuuli says of the MFMU Network. “Many of the trials that have been done within this network—some led by our very own Dwight Rouse [MD, MPH, professor of obstetrics and gynecology]—have changed how we take care of pregnant women and newborns.”
“Advances in technology have really benefited our field,” he continues. Ultrasound, for example, has progressed so much that specialists can identify and treat problems—even perform surgeries— before babies are born. Diagnosis of genetic conditions in utero no longer requires a risky amniocentesis, Tuuli adds, but a sample of blood from the mother, which carries the fetus’s DNA. “And now we are moving to the next stage, where we are attempting to sequence the whole genome of the baby from the mother’s blood,” he says.
Such progress only underscores how much work needs to be done. “The opportunities are plenty. There are still many fundamental complications of pregnancy we don’t fully understand,” Tuuli says, like preterm birth and preeclampsia. Though babies born as early as 23 weeks have a better chance now, he says, “we still don’t understand these two big syndromes enough to be able to prevent them.”
Health disparities exacerbate these challenges. “Most of the complications we are trying to prevent are more common in our Black and brown patients,” Tuuli says—30 to 50 percent more than in white patients. Therefore, researchers not only design studies to include a representative sample of the population, they also analyze the data to ensure an intervention is improving outcomes for all patients and reducing disparities.
“We are lucky to cater to 80 to 90 percent of the women in Rhode Island,” Tuuli says. “I think there’s probably no other state where one hospital can say they care for such a large proportion of the state’s population, which means the work we do here can have a true population impact.”
Paul DiSilvestro RES’94, MD, the director of the Program in Women’s Oncology and the Division of Gynecologic Oncology, returned to Providence in 2003 after his fellowship at the University of Oklahoma and several years on the faculty at Stony Brook University. When asked of his work in the smallest state, “Do you really see the gamut of gyn cancer, at least as it’s represented in the US?” he replies, “We’ve seen it all. We have such a broad mix here, from a socioeconomic and ethno-cultural perspective, and the risk factors you see with different malignancies.”
DiSilvestro, a professor of obstetrics and gynecology and an ovarian cancer researcher, helped to further develop and expand the clinical trials research program in Women’s Oncology at the hospital. He says one of the program’s priorities is “clinical trial access for every single person who walks through our door.” Brown and Women & Infants are part of NRG Oncology, a research group with members around the world, and the second-leading recruiters nationally to NCI gynecologic oncology studies within this system.
“Little known fact—Little Rhody representing out there,” DiSilvestro says. “But that’s a direct result of people being committed to the idea that these are important for not only our patients, but for all women cancer patients in general.”
There’s always room for improvement, however. The program is looking at the diversity of participants in their clinical trials and whether they represent a disease’s expected patient population. For example, “if the people that are affected by a cancer are 80 percent non-Hispanic white and 20 percent Black, then you should have that ratio in your trial enrollment,” DiSilvestro says.
Due to the history of racism, coercion, and abuse in medical research, many people are understandably hesitant to join studies, DiSilvestro acknowledges. “You have to understand that when speaking to people,” he says. “You essentially have to make very clear from the beginning that this is an option for you—in no way do you have to do this, and I will still be your provider.”
DiSilvestro is excited about several ongoing trials, including three related to immunotherapy. In September he was the lead author on a study that found a “tremendous overall survival benefit” from an ovarian cancer drug, he says. It was especially thrilling because so few trials are positive.
“But when you do hit one, the joy that comes out of it is being able to sit down with a patient who fits that diagnostic criteria and say, ‘I’ve got something really exciting to offer you,’” DiSilvestro says. “When you can actually yield an outcome that’s a direct benefit to a patient with cancer—that’s the real payoff in all of this.”
Ob/gyn researchers do much more than basic and translational science. Investigators in the Program in Women’s Oncology, for example, study issues related to survivorship and quality of life, like financial toxicity. “The trial is basically looking at the role of upfront financial counseling and its benefits to patients,” DiSilvestro says. “Maybe knowledge is power.”
Emily Miller, MD, MPH, the director of the Division of Maternal Fetal Medicine, is investigating how to integrate mental health care into obstetrics. Primary care practices have used this approach, known as the collaborative care model, for decades, she says.
“Mental health hasn’t historically been included in our training in obstetrics,” says Miller, an associate professor of obstetrics and gynecology. Meanwhile, “primary care doctors have this longitudinal relationship for years and years, ideally, with their patients. In an obstetric setting, it’s a pretty rapid turnover.”
Pregnancy and postpartum are known risk factors for mental health conditions, so screening is recommended for all pregnant patients. And while it’s “very much in the purview of an obstetric clinician to support” care for mental health conditions, Miller says, they usually have to refer patients to outside providers. “We’ve learned that one in 10 people referred out actually makes that connection,” she says. “That’s a huge drop-off.”
Some people aren’t treated because they’re reluctant to report depression or anxiety—perhaps believing them to be a normal part of pregnancy, or fearing judgment. But Miller says that about half of patients who do signal depressive symptoms don’t even get a referral. She’s also found that Black patients are more likely to be screened for perinatal depression than are white patients—yet are less likely to receive a recommendation for treatment.
“There’s no reason that race should influence whether you screen or not, when screening is universally recommended,” Miller says. “I think the only logical explanation is that implicit biases lead us to perceive a population as more at risk for mental health conditions.”
In her research, Miller has shown that collaborative care models “dramatically” reduce many of these disparities. The cornerstone is a care manager, who could be a psychiatric nurse, licensed clinical social worker, or other health professional trained in perinatal mental health as well as health equity and trauma-informed care, she says. When a patient screens positive for depressive symptoms, rather than referring them to another practice, the ob/gyn effectively sends them down the hall to the care manager, who can do additional assessments, make diagnoses, deliver psychotherapy, and offer evidence-based medication guidance to the clinician.
“We make sure that everybody is doing better by tracking symptoms, and then having weekly meetings where we discuss everybody who’s not doing better,” Miller says. People who need more resources get more resources, until remission is achieved.
Collaborative care models also take some work off the plate of ob/gyns. “Obstetric clinicians want to do the right thing. We want to be able to provide this care, we want to screen, we want to talk about it. But we’re asked to do a whole heck of a lot in 15 minutes,” Miller says. She began studying the integration of mental health into obstetrics during her MFM fellowship, when a patient with HIV died shortly after giving birth.
“She passed away from HIV-related complications. But truthfully, those HIV-related complications were because of untreated major depressive disorder and severe anxiety disorder,” says Miller, whose research at the time focused on pregnant and postpartum people with HIV. “It made me realize that I could learn all of the biology of antiretrovirals and all of the drug interactions and pharmacokinetic changes, but none of it really mattered if we weren’t holistically taking care of the person in front of us.”
In her dream world, every ob/gyn practice would have seamlessly integrated mental health care. There would be bridges between outpatient clinics and hospitals, and even to pediatricians after a baby is born, when “the birthing person is kind of an afterthought” yet is at risk for postpartum depression.
“If we could de-silo our care, we could provide better care,” she says. “So that’s the hope and dream, but, you know, give me a little bit.”
If such interdisciplinary, interconnected care models come about, it will likely be the work of current physicians-in-training, who aren’t afraid to ask why, or to push for systemic change. Miller, who came to Brown from Northwestern in July, is already enamored of the ob/gyn residents and fellows here.
“How they approach care and are so attentive to social determinants… they are champions for their patients. And that goes from the bedside to the capitol, and changing policies,” she says. “Kudos to Dayna.”
Dayna Burrell, MD, an assistant professor of obstetrics and gynecology, has worked to center the ob/gyn residency program around a vision of health equity since she became its director in 2018. A key part of that is diversifying the workforce, she says.
“If there is concordance between patients’ and providers’ shared characteristics, including race and ethnicity, there is a higher level of satisfaction with care and greater compliance with care, which can lead to better outcomes,” Burrell says, citing data from the Association of American Medical Colleges.
Achieving the goal of a diverse workforce can start with the residency program, she says. Brown’s program—like many across the nation—uses a “holistic review process, where you actually look at somebody’s lived experiences … that they’ll contribute to the program, the career, the specialty,” as well as their passions. This approach takes the focus off traditional metrics like board scores, because, for example, “an applicant may have higher scores because they had the privilege of extra time and support,” she says.
Applicants often write in their personal statements about their commitment to health equity, social justice, and reproductive rights—and the curriculum, over time, has moved to embrace those priorities. “I think that we’ve always valued diversity and diversity of thought here,” says Star Hampton, MD, the former vice chair for education in the Department of Obstetrics and Gynecology. Now, she says, the demand for social justice and advocacy training feels “more urgent.”
In 2019 the department launched a new curriculum that formalized the focus on diversity, equity, inclusion, reproductive justice, and advocacy within the core didactics. Burrell says they’re evaluating the curriculum now, “and seeing how it should evolve and change. … Talks [about]unconscious bias and upstander training and allyship are all valuable. But I think a lot of the residents are ready for, OK, what’s next? How do we apply that to our patients and community?”
Residents treat many patients who are under- or uninsured and from underrepresented, underserved populations, Burrell says—and they come to Brown specifically for that training. “The education piece of that is the importance of acknowledging how somebody’s life experiences may contribute to how they perceive care in a hospital setting,” she adds. That includes training in trauma-informed care, and didactics that explore forced sterilization of women of color and other instances of racism in the not-so-distant history of ob/gyn in the US.
“All of the health inequities and disparities that have existed in our system have inherently impacted how our patients perceive health care,” Burrell says. “It needs to be intricately woven into our residents’ education and, honestly, our faculty development to ensure that we’re doing everything we can to provide more equitable health care for every patient we see.”
That’s a future Burrell can envision, thanks to the young doctors she teaches every day. “The residents that we work with are incredibly inspiring human beings,” she says. “If we, as faculty, take a step back and listen to our trainees, then we also will be better providers for it.”
Tuuli extols Burrell’s leadership in diversifying the ob/gyn workforce; the current first-year residency class is “one of the most diverse Brown has ever had,” he says. On the faculty side, search committees designate a member who watches for implicit bias in the hiring process, and Women & Infants and Brown collaborate closely to ensure departments’ commitment to diversity. “With those efforts, we’ve actually made quite a bit of progress,” Tuuli says; recent hires have identified as LGBTQ, Black, and Asian, for example.
“We’ve been lucky—” He pauses. “It’s not luck. It is intentionality that attracted a diverse pool.” That hasn’t fully translated, yet, to nursing and other hospital staff, he admits: “There’s still a lot of work to do. No time for complacency.”
Providers are bringing intentionality to patient care with new practices like examining individual cases for bias. Hampton—who is now the senior associate dean for medical education at the Medical School, and continues to see urogynecology patients at Women & Infants—says during morbidity and mortality rounds, providers now ask, about every single case, whether bias may have affected the outcome. That might mean differential treatment due to someone’s race or ethnicity, or a language barrier, or a lack of insurance that delayed care.
“We examine the literature, and then superimpose it on the case and try to understand, was there something we could have done differently?” Hampton says. When the department implemented this practice in 2020, they did not want to pick and choose “health disparity cases,” she says, “because that totally silos out these issues, and these issues are not siloed issues. They are integral to everything we do.” She adds: “That’s really what I’m looking for in our overall medical school curriculum, is integrating DEI into everything as best we can.”
While Hampton says adding a bias review to morbidity and mortality rounds was intended as a “self-reflection exercise,” it has yielded some changes. For example, Burrell writes in an email, “this approach has helped to increase the use and documentation of interpreter services in patient care.” In fact, Tuuli says, the hospital has more than doubled the number of in-person translators and is employing more interpretation technology.
But there is only so much hospitals and health systems—let alone individual providers—can do to alleviate health disparities. While institutions can mandate implicit bias training and hire more interpreters, lack of insurance or transportation are more difficult to tackle. Tuuli mentions one recent initiative, to give free blood pressure cuffs to patients at high risk for postpartum hypertension, who are disproportionately Black and brown and need frequent blood pressure checks. The hospital hired a nurse practitioner and community health worker to facilitate the program, he says. “That’s a concrete step,” he adds, but “a comprehensive effort would take, frankly, a lot more funding.”
That’s why advocacy is becoming more and more crucial to the ob/gyn profession. Women & Infants providers have spoken out on a range of issues, from abortion rights to over-the-counter contraception access to insurance coverage for doulas. And with the State House so close, “compared to other states, it’s very feasible for our residents to be involved on a legislative level,” Burrell says. Faculty and residents also have traveled to Washington, DC, to lobby Congress to protect reproductive rights.
The Supreme Court’s reversal of Roe v. Wade in June underscored the danger in resting on one’s laurels, believing a problem is solved. “I always say it’s super dangerous when you think that you’ve gotten to the end of this work, because that doesn’t happen,” Hampton says. “We’re not done with equity for women. …As soon as we think that, we’re just going to go backwards.”
So she is “super excited” about the mindful steps forward the ob/gyn department is taking, with its intentional focus on diversity, health equity, and advocacy in everything it does. “More can always be done,” Hampton says. “I’m just excited to see it keep going.”