The South leads in hysterectomies — especially for Black women. Here’s why.
Tanika Gray Valbrun walked out of the doctor’s office, the grief slowly starting to suffocate her.
This couldn’t be happening.
By the time she reached the parking lot, she was bawling, the doctor’s words repeating over and over in her mind. She would never have children. She needed to get her uterus completely removed, a hysterectomy.
The doctor’s final words hung in the air: Forget about it, just get a surrogate.
She made her way to the parking garage, where she collapsed onto the ground as her husband, James, quickly propped her up. “We gotta get up. We gotta go.”
“I was just so devastated,” she remembered. They were newly married, and Valbrun had always wanted to be a mother. She saw a doctor for what she thought was a routine checkup. She knew she had fibroids, growths in her uterus that had caused heavy menstrual bleeding, but didn’t think they could keep her from getting pregnant.
Valbrun sought a second opinion at another hospital, where she got what sounded to her like miraculous news. She was eligible for a myomectomy, a surgery that would remove her fibroids but save her uterus and her ability to have children.
While declining in recent years because of new technologies, hysterectomy is still one of the most commonly performed surgical procedures for women. Nearly a half million hysterectomies are performed each year.
Black women in the South face the highest hysterectomy rates in the country, according to research by the Centers for Disease Control and Prevention. And an analysis of federal data by the Atlanta Journal-Constitution shows women in the broader South, defined by the U.S. Census Bureau as the area from Maryland to Texas, are more likely to have had hysterectomies than women in the north and the rest of the country.
Like Valbrun, Black women are more likely to suffer from fibroids, which often run across generations in the same family.
Methodology
The AJC analyzed hysterectomy prevalence using the CDC’s Behavioral Risk Factor Surveillance System (BRFSS), the nation’s largest health survey. To obtain the data, reporters queried the CDC’s Web Enabled Analysis Tool for state and national estimates.
The survey is conducted every year, but the question about whether someone has had a hysterectomy is only included in the survey questionnaire in even-numbered years, the latest of which was 2022. The WEAT tool applies the CDC’s weighting methodology to account for survey design, population and differences in age and race. AJC reporters exported the results of the queries, cleaned the tables and calculated comparisons across states and regions, which were defined by the Census Bureau.
Haunted by the past
Fibroids, more prevalent among Black women, are the leading reason for uterus removal among all women. But, that doesn’t completely account for the disparity in hysterectomy rates between Black and white women, said Whitney Robinson, a Duke University School of Medicine associate professor and researcher.
“The fertility of Black women has been devalued traditionally,” Robinson said.
North Carolina, where she is based, has a troubling history of state-sanctioned forced sterilization for “undesirable” Black people between 1958 and 1968, a study’s findings suggest. Women without access to birth control were among those referred for sterilization. In Mississippi, forced sterilization was so common it was referred to as the “Mississippi appendectomy.”
A lifetime of racial and socioeconomic disparities drives higher hysterectomy rates for Black women, Robinson said, pointing to limited access to cutting-edge health care and family history.
“The racial gap is just one of those really persistent things, and it’s more than just higher rates of fibroids,” said Robinson, who wrote a 2017 study showing that Black women in North Carolina lagged white woman in getting outpatient, minimally invasive hysterectomies.
Women who grow up in families where hysterectomies are common “are more likely to have a hysterectomy because that is more normalized for your family,” Dr. Kemi Doll, a gynecologic oncologist and professor at the University of Washington’s School of Medicine’s Department of Obstetrics and Gynecology.
In many cases, Doll added, these women with a familial history of hysterectomy may not know when to expect to reach menopause. Faced with severe menstrual pain and uncertainty about when it will end, that unknown alone can tip the scales toward surgery.
In her family
Valbrun was taught to respect doctors. She still dresses up for appointments. “You’re dressing up because you’re meeting a professional,” family members had told her. “You take what they say and you know it’s like Bible.”
Yet when the doctor told her she would never have children, something in Valbrun snapped.
“I knew what I wanted my outcome to be,” she said. “So there was no way that I could rest knowing that I didn’t fight to be a mother.”
She was all too familiar with fibroids and hysterectomy. Both her mother and grandmother had fibroids, and each one subsequently got a hysterectomy. Her mother lost two sets of twins to fibroids, one before Valbrun was born and one after.
Among her friends and family, Valbrun said, it’s simply called “the surgery,” reflecting the commonality of the procedure.
Knowing her mother’s experience with fibroids has helped her feel less alone, she said. But Valbrun had different options than her mother and grandmother.
During three myomectomies over the span of 10 years, Valbrun had 27 fibroids surgically removed. It was a terrible recovery.
When it was over, she was left with two things: her uterus and an idea.
As a CNN content producer and an adjunct professor in the health sciences department at Spelman College, Valbrun readily knew how to advance her plan to start the White Dress Project, a nonprofit focused on advocacy for fibroids and women’s reproductive health awareness globally.
She named the nonprofit to reflect a reality that many women with fibroids face — heavy menstrual bleeding and the quiet fear of wearing white.
“The people who have heavy bleeding, my organization resonates with them, because, you know, you understand the concept of never feeling comfortable wearing white,” Valbrun said. “What we’re trying to build at the White Dress Project is this community of self-advocacy — the idea that just because a doctor tells you something doesn’t mean that that’s your final decision.”
It’s for the women who don’t know about fibroids or hysterectomies, don’t have access to appropriative health care and don’t have the information needed to push for other options, Valbrun said.
She knows she’s one of the lucky ones.
“I get a lot of opportunities to interface with scientists and researchers and professors, etc., but I think we need a lot more people like me who have that opportunity,” she said.
Last resort
There’s a growing push — both inside and outside of the health care system — to make a hysterectomy a last resort rather than the first line of treatment. Alternatives include medication, hormonal IUDs and minimally invasive surgical procedures.
One of those alternatives is uterine fibroid embolization (UFE), a nonsurgical treatment that starves fibroids of blood so they shrink and die. Dr. John Lipman, a radiologist who runs the Atlanta Fibroid Center, performs UFE by inserting a small sheath into a blood vessel and releasing tiny particles to block the arteries feeding the fibroid.
“Information is power. How can you make an informed decision if you only know the surgical options,” he said. “Most women don’t want to undergo surgery if they knew of a procedure that didn’t require any surgery at all.”
UFE, he said, takes about 30 minutes with a recovery period of three to four hours.
Despite advancements in technology and alternatives to hysterectomy, there are certain cases when it is the only option. For Kennesaw resident Heather Walker fibroids got so big they were pushing on her uterus. She opted for a hysterectomy to get relief.
At 45, she didn’t expect to have children, and the discomfort of the fibroids in her abdomen was impossible to ignore.
When UFE and other nonsurgical options failed to shrink Crystal Davis’ fibroids, she ended up losing her uterus. She could have had a myomectomy -the surgical removal of fibroids - but she delayed it so long that the fibroids grew to the size of a grapefruit and wrapped around her intestines. A single mom from Ellenwood, with a young son, she feared having to take six weeks off of work.
“I was just scared that I wouldn’t be able to provide for my family by not working for six weeks,” she said. “I didn’t fully understand that I was doing more harm than good.”
Just before surgery, Davis begged her OB-GYN for a partial hysterectomy. While she wasn’t planning for more children, she was terrified of losing her organs. In the end, her surgeon left her cervix and ovaries intact.
Health risks
Hysterectomies when paired with ovarian removal have been linked to increased rates of heart disease, cognitive impairment and severe early menopause symptoms, recent research shows.
The procedure, in essence, triggers menopause regardless of the woman’s age.
Dr. Sujatha Reddy, an OB-GYN at Northside Hospital’s Premier Care for Women, said she is conservative about opting for surgery.
When she does operate, she wants to know that, “I’ve tried everything to avoid being there because surgeries have risks.”
Studies show that hysterectomies alone, even without ovarian removal, cause “increased long-term risk of cardiovascular and metabolic conditions.” Women under the age of 35 who underwent a hysterectomy, one study said, had a higher risk (4.6 times) of congestive heart failure and coronary artery disease (2.5 times).
There’s been a shift toward leaving the ovaries intact while performing hysterectomies, said Dr. Kristen Matteson, OB-GYN and author of the American College of Obstetricians and Gynecologists’ physicians’ guidance.
Highest in the South
Scientific research breaks the country into four regions and shows that hysterectomy rates in the Southern region are the highest of the four groups. But the data in that study, based on the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System, only goes up to 2020.
The Atlanta Journal-Constitution examined the latest available BRFSS hysterectomy data through 2022, which showed a continuing trend from the research: Black women (25.5%) and women in the South (24%) continue to report the highest rates of hysterectomy in the U.S.
The state by state breakdown shows that in Georgia Black women said they had a hysterectomy less often than white women did: 21.3% to 28.8%.
Doll and Robinson collaborated on research showing that Black women get fewer options for alternatives to hysterectomy. They have observed that the threshold for hysterectomy is generally lower in the South — both for providers, who regularly perform hysterectomies, and for patients, for whom the procedure has become normalized.
“Black women do not receive the same number of treatment alternatives prior to hysterectomy,” Doll said. When women are not offered other options like IUD, hormonal or nonhormonal medication management or more minor procedures, she added, their situation worsens and they have no other option but a hysterectomy.
Like her mother before her, Robinson underwent a hysterectomy in her 40s. She later learned the surgery could have avoided. A fibroid had degenerated and caused her worsening pain and bleeding, but she was misdiagnosed and didn’t get fibroid treatment in time.
“They would have had to do an MRI, probably, to really see what was happening,” she said. “If I had seen somebody who was a specialist, who was more dedicated to figuring out my underlying problem, they would have been able to properly diagnose that, and that could have changed it.”
Doll has seen the difference between attitudes toward hysterectomy in the North and South firsthand.
“I trained in New York and Chicago and the South, in North Carolina, and then now I’m in Seattle, and hysterectomy is just so much more normalized in the South,” Doll said.
It’s both access and attitude.
Georgia’s women’s health care deserts
Like Robinson, many women in the South do not have access to adequate women’s health care from the start, which could prevent a serious surgery like a hysterectomy.
Georgia is falling behind for maternal and child health care even when compared to other Southern states, said Tamara Mason, director of the Maternal and Child Health Collective Impact at the March of Dimes. The collective works to reduce inequities in preterm births and maternal mortality.
In more than 40% of Georgia’s 159 counties, women do not have access to an OB-GYN at all, according to a 2024 March of Dimes study. The research also showed that access to care is worsening in Georgia and nationwide as the number of maternity care “deserts,” increase resulting in more areas where there are no hospitals with obstetric care and zero OB-GYNs, certified nurse midwives, certified midwives or family physicians who deliver babies.
In health care deserts, women may travel hours to reach the nearest provider. Even when OB-GYNs are available in rural areas, they may not have access to the tools and technologies to perform procedures that avoid hysterectomies.
Rural areas may also have providers who are decades removed from their medical training and not as aware of the latest technologies that allow for alternative treatments, Doll said.
“I trained in New York and Chicago and the South, in North Carolina, and then now I'm in Seattle, and hysterectomy is just so much more normalized in the South."
For the patient, traveling for follow-ups every few months may be difficult or impossible, making a “one and done” option like hysterectomy more appealing. Some procedures also require specialists, which could involve even more travel.
“A lot of times doctors are being dismissive and they’re only offering hysterectomy because it’s just what they know, what they’ve seen or haven’t seen, that guides their perspective on how a patient should be treated,” Valbrun said.
Gaps in care also stem from state policy.
States with limits on Medicaid, like Georgia, see high rates of uninsured populations, usually women in their prime working years when hysterectomies often occur, Robinson said.
Women who are in health care deserts, uninsured or both lack access to quality women’s health care, which leads to complications down the road and, often, hysterectomy. In a post-Roe era, states with tight abortion restrictions see even more fallout for women’s health care access all around with less maternity health providers available, a recent study said. Women in states like Georgia are also most at risk for skipping necessary care due to cost without health insurance.
White Dress Project
Valbrun’s personal journey reinforced her commitment to The White Dress Project and helping other women experience what she’s been able to — the joy of living fibroid-free while not sacrificing the ability to give birth.
The White Dress Project celebrated its 11th year anniversary in July with a “Night in White” gala in New York City and an empowered patient summit in partnership with NYU Langone Health’s Center for Fibroid Care.
The gala, the nonprofit’s prime fundraiser, honors people who are doing the work around fibroids in medicine, science and the law. The White Dress Project, founded by Valbrun 11 years ago, provides education on treatments, hosts events to link women with doctors and advocates for legislation to fund fibroids research. It has raised more than $200,000 to fund the work and help women attend the events, federal tax records show.
“It’s a time for our community to really rally around each other and support each other,” Valbrun said.
The White Dress Project has taken Valbrun around the world. In the United States she worked to establish July as National Fibroids Awareness Month. Internationally, she has advocated for more awareness about fibroids in India, Ghana, South Africa and England.
“If we can have more of these real conversations, real storytelling points, then it will inform and influence the research and the data,” she said.
‘It’s just all worth it.’
For Valbrun, the successful removal of her fibroids in 2013, 2018 and 2023 changed her life.
A decade after her first myomectomy, Valbrun was pregnant.
“I was like, ‘Oh my gosh, this is it,’” she said. “On our 10th (wedding) anniversary — what a beautiful story.”
That joy, however, was fleeting. Just a few months later, she suffered a miscarriage. The heartbreak was intense, but she didn’t give up.
Months later, on the 10th anniversary of The White Dress Project, she became pregnant again, and this time, everything went smoothly. In February, their perseverance was rewarded when the Valbruns welcomed their son, Jasai Kristian Valbrun, into the world.
“It’s very surreal,” Tanika Valbrun said. “I’m much happier, even though parenting is the hardest job in the world — like everybody says. Just looking at his face every day, it’s just all worth it.”
About the Authors
Justin Price is a data reporter who works to uncover societal issues, disparities, and injustices. He joined the Atlanta Journal-Constitution in 2023 from Phoenix where he spent five years as a journalist on the investigative team at The Arizona Republic, shining light on prison labor, police misconduct and charter schools.
