#125 | Uterine Fibroids in Pregnancy: Their Impact on Birth, Uterine Scars, and How Black Women are Affected the Most

Women, especially black women aren't given the agency to make decisions that are best for them with the right information. And I think especially as a woman who's had fibroids, a woman that's had a myomectomy, a woman that's had to advocate like hell to have a vaginal birth, I came to realize that all the providers that told me no, they never even asked me, What do you want to do? There was never an engagement of what my options were, I was just told what I couldn't do. And so finally, that pissed me off and I just started looking for providers who would support me, and it took me about, I probably saw about 10 to 12 doctors before I found one who said, You know what, let's do it.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

Mabel Bashorun is a certified doula, Lamaze certified childbirth educator and certified lactation consultant. Her journey into birth work stems from her unique story of trying to conceive while dealing with a fibroid diagnosis as well as being moved by the traumatic birth experiences of several friends. In 2017 she started Within Her Birth Services with the mission to support and advocate for other women throughout their pregnancy and labor experience. As a Ghanaian American, she has great pride in serving fellow Black women during pregnancy, with a personal aim to ensure they do not succumb to the maternal mortality crisis that plagues the black community today. Mabel is based in Northern Virginia. Mabel, thank you so much for taking the time to be with us today on the podcast.

It is a huge honor to be a part of this conversation.

So we understand you have a lot to say about fibroids. So can you give us a little background on how you became so knowledgeable in this field?

Yeah, so scaling back to even before I got pregnant. I got married around age 26. And shortly after I got married my husband and I decided that we wanted to wait until we got pregnant. And in that interim, I went on to do a physical at my doctor's office and found out I was extremely anemic. And so that doctor told me to go to my OB and inquire to see why I had such a low blood count. And through that experience, I came to find out that I had fibroids. Now mind you I have heard of fibroids. I actually kind of assumed that women who had fibroids were much older because a lot of the women in my community that had fibroids were like menopausal. So I was a bit stunned that at 26 I had fibroids and I had many of them and it was impacting my health greatly. And no one ever told me about that no one told me that fibroids was something that I should look out for when it came to my women's health. And so through that experience, I just dug really deep into the world of you know uterine fibroids, how it may impact someone's life, why women get it. I was stunned to find out that black women are highly susceptible to getting fibroids. I think the research shows that eight out of 10 black women will experience fibroids at one point in their life. Women of all backgrounds are impacted by fibroids one way or another. But black women have the highest rates of fibroids. And so I was quite certain that you know, as a young black woman, no one told me that was something I had to be, you know, on alert for, and I had to learn how to, you know, start this life a new trying to deal with this new diagnosis.

Can you explain what fibroids are and then whether they understand why there is such a high correlation between fibroids and black women?

Yeah. So a five point is a benign uterine tumor. It's it's a small or large growth that may occur in the uterus. It can occur inside the uterus, within the wall of the uterus or outside of the uterine cavity. They can be small in number or they can grow to be almost The size of a watermelon. It's amazing how every woman who's had a fibroid has a different experience in terms of how it may grow. It usually happens during your childbearing years. So anytime from the time a woman gets her period to the time when she no longer gets her period, she is likely to get a fibroid, because they're non cancerous. I have found that there isn't much research that is done. There's not a lot of literature out there explaining why fibroids happen and why they are plaguing black women at the rate that it is, as far as I know. There hasn't been much research to kind of draw that correlation. But we do know that black women have a high rate of getting fibroids because I think fibroids are mostly linked to a hormonal imbalance. I will strongly suggest women, you know, get checked up often. I believe the research shows that women who have a low, low estrogen, not just progesterone, but I think it's vitamin D. Yes, yes, women who are low in vitamin D are at high risk of getting fibroids. Black women are notoriously low in vitamin D. And therefore I think that's a huge link as well. But many women don't know that until again, you're pregnant or you have to do a CBC for one reason or the other. I think that getting an annual physical could just be the start. And also asking your OB to do an ultrasound, even if you're not pregnant, it just to see what's going on there. I've had so many friends who you know, after they heard my story, they went to their doctor insisted on an ultrasound and found out they have fibroids, and they have no idea they have fibroids. Granted, not every fibroid is problematic. Many women go on to have fibroids and have normal, safe, healthy lives. But there are some times where it can be problematic. So it's important to get checked, and have that conversation with your provider constantly.

And on my on my understanding of fibroid growth has to do not entirely but they it is influenced by estrogen metabolism. And that, of course, is why you see more fibroids once you enter your reproductive years. And they also can get significantly worse in pregnancy because of the high estrogen levels. So we're going to talk about that. Right?

Absolutely. We'll talk about that. And it's very interesting that a lot of women don't know that they have fibroids until they become pregnant and they see it on a an ultrasound scan. However, I think there are signs that can kind of point to fibroids even before pregnancy. I know for me, it was anemia. And looking back, it was like perfectly clear that I had an issue I was experiencing extreme blood loss with every period. I mean, to the point that I was bleeding through my clothes, I was bleeding in traffic, I was bleeding. When I stood I was bleeding when I sat it was intense. But as a young 20 year old when you google heavy blood loss, then you assume that you're just you know, that's just how it's going to be for you. Also, I experience a lot of pelvic pain, a lot of intense pain in my pelvic area. For some other women, they may experience the same type of symptoms. I've heard some women experience actually seeing a bulge in their belly area. That doesn't seem to go away for some reason. But there are many signs that points have fibroids, and unfortunately, we kind of assume it to be normal, you know, so then we don't tend to treat it in a timely manner.

So why is it so common with black women? Do they think?

I don't know.

Yeah, not well, not well researched?

It is not well researched at all? I know there are several um, I mean, women with eight and 10 Black women will experience it. Is it like seven in 10 white women or like one in 10? White women? Do we have any?

I think it's quite high amongst white women as well. I'm not as high but I think it's high as well in the white community as well. But they're quite common in general. What is really the distinction is that you know, the small fibroids don't have much impact. They don't really you know, they're not that noticeable. They may not be influencing your menstrual cycle, they may not be influencing your pregnancy, but large fibroids or depending on where they are can have a very significant impact on everything in your reproductive cycle.

Yeah, especially depending on the size and the placement of the side right. It can certainly impact your fertility. Um, you know, when I was talking to another advocate about fibroid health, and she said when she began lobbying for you know, five Word research. A lot of professional said that well, no one's dying from fibroids. So it's not really that important to really seek more information, you know if we can deal with it through a birth control pill, if we can deal with it through surgery, then what's the point of really trying to dig deep into finding out the cause?

And to that, I want to say no one is dying from erectile dysfunction either. But how much money have we poured into that industry?

Exactly, exactly. And if you even want to take it a little deeper, you know, for some women fibroids has been the cause of miscarriage for them. And if you look at it from that perspective, you know, if if women are losing babies, babies are dying, that's a death in its own right. And so therefore, it does deserve more research and more insight, and more help for prevention. But unfortunately, that hasn't happened just yet. But I've taken it upon myself to advocate within my own community. As a doula as a sister as a friend. I'm always urging women to take control of their female health.

So tell us about how fibroids can impact pregnancy.

Yeah, so like I said, a lot of women don't come to find out about fibroids until they're pregnant. And so depending on the size of the fibroid, it can compete with the baby's growth. Knowing that as a woman progresses through her pregnancy, you know, baby has to grow baby has to find room in the uterus. And if you have a fibroid, or more than one, there may be issues when it comes to babies having a chance to grow appropriately. In some unique cases, it can impact delivery to the extent that there might be premature delivery. I have witnessed in my own personal circle, friends who've had to be on consistent bedrest because of the intense pelvic pain from fibroids as well. But I will be honest, and say for many other women, it's not that severe. For some women there, they may have a fibroid, and it may be non problematic. So it varies from woman to woman. But I think that regardless of the impact of your pregnancy, it's important to know how that fibroid may make a difference to your health, even after delivery.

And it actually can even impact your mode of delivery. So some women will have fibroids that are in place where they have to have a cesarean. And if it's a significant enough fibroid, and it has to be removed with a certain type of incision, it can impact future pregnancies too, even after it's removed, because then they're considered high risk because of the type of scar they had for the fibroid removal.

Do they just keep growing larger? They do. So can in case they do go on? Go ahead.

Oh, so I was saying in some cases, they do grow larger. And some cases they don't. In some cases, they may degenerate, which is actually they may break down and get smaller. So I know for me, I had a fibroid when I was pregnant with my firstborn. And I experienced degeneration around the 24th or 25th week mark. And it was aggravating pain, like pain beyond measure. And I can't even describe it to you, but I just knew that something was wrong. And I just had to kind of, you know, cope with it until that pain went away. Thankfully, it didn't last for a long time, but I knew that it had to do with my fibroid, and there was nothing much that I could do about that.

So what goes into the decision as to when women get fibroids removed?

Yeah, that's a good question. So when a fibroid is impacting your way of life, meaning that you have such terrible painful periods, or heavy periods or intense pain, if it comes to a point where it's impacting how you live and your lifestyle, I think a lot of women take it upon themselves to seek support or seek help. So for some women they may be a doctor may suggest that they go on birth control pill. Apparently, birth control may help with, you know, managing the symptoms of fibroids, and most cases, women would be told to consider surgery. And so the name of the surgery to remove a fibroid is called a myomectomy. And there are different types there's an open myomectomy and that's when they enter the uterus as if they go through as if it's like a C section, and they remove the tumor the fibrate that way, or lap scopic is another way that they may remove the fibroid as well, where they enter the uterus through small incisions and they cut the fibroid into small pieces and then remove it out of the uterus that way. There are some other new ways to remove fibroids. I believe there's another one called uterine fibroid embolization. I'm not too familiar about the details of that. But I do know that myomectomy is the one of the top ways that fibroids are removed. And then unfortunately, for some women who have a crazy amount of fibroids, they may be told that there's no other way to remove them, except through hysterectomies. And so I think that it depending on where you are in your life, you would know what decision is best to make. I have known some individuals who've gone on to have a hysterectomy, even though they did not desire one, but their fibroids had plagued their uterus beyond repair.

Is a myomectomy any means of removing a fibroid? Or is a myomectomy the method in which they make an incision and go directly into the uterus. And you end up with a scar.

Yes, so it is the way in which they enter the uterus to remove the fibroid.

So after such a surgery, if a woman is pregnant, she then has scar tissue. And did they put those women in the same category as a VBAC woman, um,

from my personal experience, I will actually say no. So because my anatomy involves entering the uterine cavity, and because you're moving, not a baby, but you're moving several tumors in different parts of your uterus. A lot of doctors feel very uncomfortable to allow or support, right support, because we know about that allow word, but to support a woman in pursuing a vaginal birth after myomectomy. Now, this is where I think my story kind of comes in again, because if you look at the evidence, majority of the evidence points to the fact that women who've had a myomectomy despite how many times the uterus has been entered, they may still be a feasible candidate for a vaginal birth after that procedure. But there hasn't been much research done to support that. And I think a lot of doctors still feel quite uncomfortable. And so they feel that it is best that a woman who's had a myomectomy they should pursue having a C section to reduce the risk of uterine rupture. From all that I have read, there is probably more of a higher chance that women who've had a myomectomy they may be very successful and having a vaginal birth, but I believe that risk of uterine rupture has, you know, kind of taken over a lot of providers minds. And the fact that, you know, there's a risk and so they don't even want to, you know, support any woman to do that. In my case, after I had my laparoscopic myomectomy I sat down with the surgeon and she told me flat out. No, you can't have a vaginal birth. It's too risky. Your uterus can rupture. Although she did not enter my uterine cavity. My fibroids were within the wall of the uterus. And so my the uterus actually wasn't breached. How can she say you couldn't have a vaginal birth then? Well, that's a good question.

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I think you know I if you really look at the bigger picture. A lot of providers feel that way. They feel like oh, you know you've endured this you know great surgery. Now your body is incapable of doing anything more outside of going through, and that's their surgery.

The thing is, they're not looking into the details, they're just saying, because you had uterine surgery of some kind, you're at higher risk for uterine rupture. So this is where it becomes extremely important. For the woman who chooses to have whatever type of fibroid removal procedure, she has to make sure she has access to those records, to make sure she's really clear about what type of procedure she's having. Because there are some procedures, as you mentioned, that have zero impact on her her mode of delivery when she has a baby. And so when you are having the discussion with your provider about whether or not you should have fibroid removal, it's also really important to express your birth preferences at that time, it is it can be done differently. And when you go to your future provider midwife, or OB whoever that may be, you must have clear records of what type of procedure you have.

You know, it's it's so good that you say that Trisha, but from what I gather, no matter the evidence, or records that you have, from your surgery, it's series very difficult for women with a scar, a special scar like mine, to pursue vaginal birth, it's not impossible, but you will be faced with, with so much pushback, that it can be very discouraging. And it's especially difficult when you know that your uterus hasn't been as impacted as someone else who's actually gone through, you know, like a C section or say even an abdominal myomectomy.

Well, look how hard it is. Look how hard it is for moms who are, you know, wanting to have a VBAC we already know we already have good evidence, there's tons of evidence that feedback is safe. And it's still really hard to get people on board. So you can imagine with an special scar or unknown type of scar that you know, the go to is just no.

And Mabel, I have to just ask your agony and American, you're very well informed on maternal mortality rates for all women, and in particular, for black women in the United States. In a situation like that, did it cross your mind? Am I being treated differently? Because I'm black? Is this one of those instances where they're putting me in a different category? Because I'm black? Do you have to question that and wonder that at each junction, when you're faced with these suggestions that you know, aren't evidence based, does that come up easily or all on?

It comes up all the time. And even as a doula who supports mostly black women, I'm always thinking about that. It's amazing, the pushback that we face sometimes, or the belittling that we may face at times. And then also, not every scenario is like that, but the majority of my experiences have, you know, I felt like I've had to safeguard, you know, my clients or advocate in ways that I've never had to advocate before. Because I think now that the conversation of, you know, maternal mortality in the black community is getting a lot more recognition, I find that a lot more obese, or providers in general, are, I want to say, like jumping the gun. It's like they want to avoid the mortality, so much so that they over intervene. If I'm making any sense here.

Well, but it's the over intervening that's driving up the mortality rates. So that argument is something I always grapple with. I mean, and if they, if they're really aware of what's causing the high mortality rates, they should know better, they should be more hesitant to intervene without evidence. So I never know what I think of that argument or like the litigation argument, oh, we just don't, we just have to be worried about litigation. And I always want to say, well, you're more likely to end up in litigation if you create an adverse outcome, right. So you know, you wonder if it's, is it? Is it really bad? Is it in your best interest? Is it that they're not informed? Is it that they're not giving you the autonomy that you deserve?

That's what it is. Women, especially black women aren't given the agency to make decisions that are best for them with the right information. And I think especially as a woman who's had fibroids, a woman that's had a myomectomy, a woman that's had to advocate like hell to have a vaginal birth. I came to realize that all the providers that told me no, i You can't do it because of a rupture. They never even asked me. What do you want to do or what are ways in which we can go about this? At the time when I had my surgery? The surgeon told me no, you can't have a vaginal birth. But she never told me like, well, let's talk about spacing out between the time you had your surgery, and then the time you get pregnant, she never talked to me about ways in which I can best take care of my body, in the hopes that it will be healthy and strong to be able to have a successful vaginal birth. There was never an engagement of what my options were, I was just told what I couldn't do. And so finally, that pissed me off, and I just started looking for providers who would support me, and it took me about, I probably thought about 10 to 12. Doctors before I found one who said, You know what, let's do it. But that was 10, almost a dozen doctors that told me no.

And how many women would not be willing to go through a fraction of that effort? Right? Or have that determination? I think you're pointing to I think you just outlined very well, that what we are all looking for is a provider who will partner with us, right? Because they have information that we don't have, and we need and we want and we appreciate. But we have the baby, we have the body, we have the life that is behind this experience. And you are with providers, as so many women are who just believe it's their job to lay down the law. And as we just shared in our last interview episode with Barbara Harper, they're painfully misinformed when they get out of medical school, and they go have seminars with women like her and get educated in many respects for the first time, because they're not really given the information they need to support women optimally. But you knew better so you went through that effort?

Oh, yeah, I knew better. And I think every time I got to know, it just empowered me to keep pushing. And you know, the amazing thing is that I was a worthy candidate for a vaginal birth. I was still quite young, I it had been almost over a year since my procedure, my uterine cavity wasn't breached, I was a worthy candidate. And all I was asking for was individualized care. Now I know that there's this risk of uterine rupture. But if you took me as an individual, as someone sitting in your office, one on one, and you took me as almost like a special case, you will be surprised that the outcome would be much better than you expected. And I think that's what's lacking. That's what's lacking in maternal care today, no one's individualizing patients, no one's individualizing. Women, we're just looking at it like, Oh, you've had this history, and therefore you're disqualified. And so many women are being shuffled, having C sections, despite having a unique uterine surgery background, but we will never really know if they were truly capable or not, because they were never given the chance.

And of course, they're acting as though it's their decision to make and not yours. What about just letting you take the risk with your potty, the only providers that listen to me and gave me a chance were midwives. I saw one provider, and he was an older OBGYN, phenomenal doctor, based here in Northern Virginia. Unfortunately, when I was pregnant, he passed away unexpectedly. And so I was scrambling looking for a provider because here I am, 30 weeks pregnant, it took me almost a year to find this doctor, he passes away now who was going to take me and and my unique history. And I went to a midwife, and I sat down in her office for an hour, and I told her, I'm having a vaginal birth, and you have to support me, and she never not once made me feel inadequate, and capable, she was even excited to be able to support me to have this opportunity. And when I found out about this group called Special scars, it's a nonprofit group for women who've had a unique uterine procedure. So whether it's a classical incision, or T inverted incision, or J incision, there's so many different types of incisions out there that women may have to go through, for one case or the other. It's a group of women who had a unique uterine surgery, and they just want to find out more about their options in the future, whether it's having a repeat C section, or pursuing a vaginal birth after that special scar. And after obtaining all of this information, and reading the evidence and doing the work and doing the research, we've come to find that despite the history or just Despite, you know, our surgery, with the appropriate support, we may be very successful. And even for women who go on to have a second or third C section, they are empowered in that decision making.

Because it was a choice. That's because it was because it was a choice.

Right? When I joined the group, and I just started, you know, reading everyone's encounter, majority of the women who've been able to have a vaginal birth after their special scar did so with the midwife, whether it was in hospital or out of hospital. And I'm just, I was just so amazed at how the midwifery model of care, even though we Herald it to be for women who are low risk, quote, unquote, that women who still have a unique, you know, background may still benefit from the support and the guidance of a midwife. And I think it's not because you know, a midwife is better than an OB or vice versa. But I think midwives are more willing to listen and to trust the body. And I think through that support and appropriate guidance, women are able to meet the goals that they truly desire.

Right, I mean, many midwives will do VBAC at home after two cesarean that's not considered low risk. Look at Dr. Stu, who is an obstetrician by training, but he practices the midwifery model of care and he does reach birth at home, he does twin birth at home. So it doesn't necessarily have to be low risk. It is about taking the individual situation, evaluating it and making an informed choice between the birthing person, the mother and the provider.

I really like what you said about choice earlier, because when I have a client who, let's say, you know, takes my class in month, six or seven of pregnancy, and then they call me at the end, they sometimes are in a little bit of a panic because their baby is breech. And they say something like Well, now I have to have a C section and I say no, you don't have to have a C section. I've had clients who've had vaginal breech births in, in Yale at home, Amish country, Episode Seven with Jessica. So I say look, if you want to have a vaginal breech birth, we can get busy and find you the midwife who will support that I know one in Massachusetts, who will very likely do it. I know I know, may Gaskin at the farm in Tennessee. Do you want to go to Tennessee? And usually then the women say Well, no, I don't think I want to do that. Would you want to have a home birth to breech baby? I don't think I'd want to do that. Okay, so would you like to choose a C section? Because that's a choice. And it's a very different feeling than saying my provider said I had to have a C section. It's very different to say, Well, I do have the option for a vaginal birth. I'll turn it down or I'll take it. But if I turn down that option, now I can have that C section feeling empowered. And then of course, the next question which we won't get into is now do I wait till I go into labor naturally, or have a scheduled C section but we must always remember we have choice. We always have choice. We always choice. So I love that you said that because I almost never hear anyone. You know, articulate things that way women really believe they run out of options. And you're never without options. The simple fact is many realize they choose induction they choose a C section under the right circumstances and then that is the right choice for them.I think the final point that I like to make is that because black women are such at high risk of getting fibroids, I do believe that majority of said women will probably remedy that diagnosis through surgery, whether it's through a myomectomy or even a hysterectomy. And then when you look at the bigger picture of what's going on in America, with the fact that black woman have the highest rate of C section in this country, and then we also are at high risk of maternal mortality. But I feel like there is a common thread that's going on here in regard to reproductive health and how women, black women are being able to be given a chance to really take control of their well women's wellness. And I just hope that if anyone whether is a black woman or not ever gets a fibroid diagnosis, but I hope that they're not thinking that it's a one and done situation for them that after you get a myomectomy that you must have Have a C section, by all means necessary. I hope that if she does choose to have a C section, it's because she strongly feels that is the best choice for her. Not because a doctor has said so not because a doctor has scared her into thinking that she or her baby, they're going to die or, you know, it's going to, you know, terminate her chances of being able to get pregnant again. But I hope that if anyone ever does pursue myomectomy, that she should know that she still has a choice in what her prenatal experience can look like. Unfortunately, so many women are told that they have to do something. And in the end, they are missing out on an opportunity that might be life changing and supportive to another woman. I'm grateful that I had a supportive team. It took a lot of work. But when I look back, it was worth it. I had a vaginal birth, my son was over nine pounds. I had gestational diabetes, I had almost everything that was pointing to a C section at that point, but I still went through and had a great experience. Not once but twice. My second delivery was at a birthing center, and I had a beautiful waterbirth. And you know, when I look back at that, I'm like, wow, I was really empowered to to have these birthing experiences, despite all of these doctors telling me otherwise. And it was truly worth it. And I wish that for other women, especially if they truly hope to have a similar experience as well.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and  as always, hear everyone and listen to yourself.

I recommend this podcast to every client of mine and I'm always reposting on Instagram you would think like I'm your third host or something like I've always been posting and sharing it's it's such a powerful tool for women to have you two. I can hear in your voices how sincere and how deep your love for midwifery and for women's rights and for, you know, prenatal care. I can sense it in my soul when I listen to you all and I'm so proud of what you all are doing. It's important to everyone, especially as black women to know that the power is in our hands. And I think that's what you guys tell us every episode you are reminding women that the power is in your hands and God bless you for that. God bless you for that.