LANDER—Jan Siebersma has delivered thousands of babies during his three-plus decades in obstetrics. He’s seen it all: twins and breech babies, marathon labors, emergency cesarean sections, even the rare en caul delivery when the infant emerges in the intact amniotic sac.
Working in Fremont County for the past 15 years has kept him busy. The New Hampshire-sized county is home to nearly 40,000 people and several towns, but as of 2016, Lander is the only one with a hospital that delivers babies.
As recently as 2021 Siebersma provided care alongside another OB and two midwives at the Lander Medical Clinic; all four delivered at the hospital. There was also a private practice in town. “We had a nice amount of providers, and a relatively nice life,” said Siebersma, a tall man who keeps his gray hair cropped short.
But then the clinic’s other obstetrician stopped working due to a medical issue, and one of the midwives left the practice.
“So then, [midwife] Sam Skelton and myself were left with a practice that had been built up for four people,” he said. “The thing about obstetrics, you can’t just turn the faucet on and turn the faucet off. So during that time, I just really got burned out.”
Siebersma tried to facilitate the hiring of another OB to relieve the burden, even asking the hospital to recruit another provider. But ultimately, he had to step away. Siebersma delivered his final patient’s baby in early 2023.
That left Dr. Thomas Dunaway, who employs a midwife, as the sole obstetrician serving the general population of pregnant patients in Fremont County. (Tribal patients on the Wind River Indian Reservation have access to specifically contracted doctors.) Dunaway did not respond to several interview requests.
Siebersma continues to see gynecological patients. He also works as a locum tenens doctor for SageWest, meaning he takes on-call shifts to deliver babies. But unlike before, the patients are not women he’s previously established care with and seen for prenatal checks.
Taking locums calls “is vastly different than having, you know, 150 patients that are pregnant that I’m responsible for,” Siebersma said. That type of workload is what you sign up for as a rural obstetrician, he noted. “But there comes a point where … enough is enough. It gets onerous after a while, constantly being available.”
Siebersma’s story of spending inordinate hours helping bring babies into the world — perhaps to the detriment of his own health and family life — is common among rural obstetricians, according to interviews with medical staff and experts.
His decision to stop practicing obstetrics is one piece in a complex puzzle of factors that have eroded services in this sprawling central Wyoming county, and the state as a whole. Though Wyoming has 23 counties, it is home to just 18 birthing facilities. Several facilities have shuttered labor-and-delivery units in recent years. Doctors have retired, closed offices, limited their practices or left the state to practice elsewhere. The providers who remain are left to grapple with taxing call schedules, the uncertainty of relying on unfamiliar traveling nurses and the responsibility for many patients with little backup.
Lander’s SageWest Health Care hospital has recruited a new obstetrician who will start at the hospital in 2024, CEO John Whiteside said, along with a family practitioner who can deliver babies.
“The desire in my heart is still that I do want to work and help the people of Wyoming … Sometimes things have to break for them to get fixed.” NATALIE EGGLESTON, , OB-GYN WHO GREW UP IN JACKSON
Having more hands on deck could help, providers say, but is unlikely to change the predominant climate of gusting headwinds.
Shrinking obstetric options have consequences not only for providers, but for their patients. Many women here travel for maternity care, risking dangerous road conditions and adverse outcomes. In part two of this series examining Fremont County’s OB shortage, WyoFile looks at the impacts on the oversubscribed medical professionals keeping the system afloat.
‘Couldn’t make it work’
Nurse midwife and mother of four Chase Ommen grew up in Riverton. She has many years of experience in Fremont County’s OB realm — she worked as a labor and delivery nurse in the nearby Lander hospital and later as a nurse midwife at the Lander Medical Clinic, providing a range of women’s health care services and delivering babies in the hospital.
Ommen started as an OB hospital nurse in 2011, and looks back at that time fondly.
“We were a rocking team,” she said. “We had great nurses, great providers, we had an amazing manager of our unit. And we all worked together very well. The community had choices in providers at that time, and that’s huge for a patient … and also, we provided really great, up-to-date, evidence-based care.”
There was healthy competition between the Lander and Riverton hospitals, she said. Then in 2016, SageWest, both hospitals’ out-of-state, for-profit owner, closed the Riverton OB unit and consolidated the campuses’ services. Lander’s birth volume spiked, Ommen said, and her manager became saddled with too much work and too few resources, ultimately resigning. Many felt the support from administration “wasn’t there.”
The situation didn’t improve. Working as a midwife years later, she recalls spending her days seeing patients in the clinic and her nights in the hospital delivering babies. She barely slept. “It was awful,” she said.
Ultimately, she said, she hit too many barriers — financial and otherwise — to practice midwifery in Lander. She found a midwifery and family practice position in Billings, Montana, packed up her family and left Wyoming.
“It was really really hard for us to leave Lander,” Ommen said. “Not what we wanted.”
When Siebersma ended his OB practice, nurse midwife Skelton’s services were also lost to the community. That’s because she had a collaborative agreement with Siebersma; the hospital requires such an arrangement for a nurse midwife to deliver.
Skelton said the gaps in care are hard on families. “The idea that you will likely get prenatal care and then go in and have someone completely different show up for your birth, I think that’s anxiety-inducing for a lot of women.”
Certified professional midwife Heidi Stearns helped Fremont County mothers have home births for 15 years until she retired at age 65 in June.
With her retirement, she said, women seeking home birth options must look to midwives who are willing to travel to Fremont County from elsewhere. She refers people to a Worland-based midwife. Worland is 88 miles from Riverton and more than 100 from Lander.
Rural midwifery is tough to sustain, Stearns said — you are on your own in many ways. The specter of an abortion ban in Wyoming and other states also weighs heavily on midwives like herself, Stearns said. For example, she used misoprostol, which abortion opponents have targeted, for treating postpartum hemorrhaging.
“It’s really scary to do births without those medications,” Stearns said.
In Idaho, anti-choice laws have driven many OB-GYNs from the state, leaving women and pregnant patients with few choices in a newly deserted health care landscape. Wyoming lawmakers have passed a pair of abortion bans, though enforcement has been held up in the courts.
“I think Idaho is a good model of what would come if all the bans went into effect” in Wyoming, said Jackson OB-GYN Giovannina Anthony, who is among the plaintiffs challenging Wyoming’s bans in court.
Incentives and disincentives
Obstetrics is not as profitable a specialty as many others, which experts say is one factor driving rural hospital labor and delivery closures. A 2022 study on rural obstetric challenges found that about 40% of rural hospitals lose money on their obstetrics programs due to factors such as Medicaid reimbursement rates. In addition, medical liability insurance premium rates are higher as a percent of gross income for specialties considered high-risk, such as obstetrics.
Another challenge to the specialty involves volume. Doctors need a large enough patient base to treat the gamut of issues and keep their skills sharp. In obstetrics, ideally that means lots of normal births as well as the complicated cases, which can be valuable learning experiences.
Rural areas often lack that volume. They are often also short on other medical resources found in urban centers, including specialists who can help with complicated cases and enough colleagues to share the call-schedule load. Retaining support staff has also been a challenge even as employees like nurses and anesthesiologists are vital for delivery wards.
Those and other factors make it difficult for rural facilities to compete with urban centers for doctors. Wyoming has long grappled with this.
The University of Wyoming participates in the WWAMI Medical Education Program, which is affiliated with the University of Washington School of Medicine. It’s considered one of the state’s strongest levers for keeping promising young doctors in the state. The program is designed to be a win-win — if a participating student goes to work in a designated underserved rural area, the program pays back up to 75% of their tuition costs for the returned service. The Wyoming Legislature funds 20 seats annually in the program.
Growing up in Jackson, Natalie Eggleston always wanted to be a doctor. When she learned about WWAMI as a teenager, she figured she’d found her ticket. “It was like, ‘all right, that’s how I get to medical school.’”
After her undergraduate studies in Utah, she was accepted into the selective WWAMI program and pursued obstetrics as a specialty.
She completed her residency and OB-GYN training in California. When it was time to come back to Wyoming, however, she started having second thoughts. She worried that the Roe v. Wade reversal, and Wyoming’s abortion-ban laws, would affect her ability to provide full reproductive care to patients.
“To imagine myself coming back to a place where I would have to basically put my own security and my job potentially ahead of what I know to be the right type of care to offer patients … It kind of seemed like an impossible place to put myself in so early in my career,” she said.
Other challenges of rural medicine factored in. She started to realize how low-resourced some of the practices were and how difficult mentors would be to come by.
“I kind of wanted to keep some of my volume and my resources high before I was ready to be the best doctor that I could be in a rural area,” she said.
And in Jackson, where she strongly considered returning, the cost of living is too high even for many doctors to afford, she said.
So Eggleston instead accepted an OB-GYN position in Billings. There is still time to return to Wyoming and claim WWAMI’s financial incentives. If she doesn’t, however, she will miss out on about $250,000 in loan repayments.
“The desire in my heart is still that I do want to work and help the people of Wyoming,” she said. “Sometimes things have to break for them to get fixed.”
As of 2022, 131 out of 194 Wyoming-WWAMI graduates, or about 68%, have completed residency and returned to Wyoming to practice medicine, according to the University of Wyoming.
Fremont County families had 442 babies last year, according to state records, but only 339 were born in the county, indicating that 103 babies — almost one in four — were delivered elsewhere. That translates to an increased load on obstetric providers in places like Thermopolis, Jackson and even other states.
Hot Springs County’s delivery numbers jumped by 65% between 2011 and 2022.
“Fremont County, it’s a heck of a lot bigger than Hot Springs,” said Dr. Travis Bomengen, a Thermopolis family practitioner who provides OB care at Hot Springs Health. “And so, our numbers have gone up from that standpoint.”
The trend has spurred staffing changes to ensure enough providers are on hand, Bomengen said. Hot Springs Health has satellite clinics, including one in Riverton. They held off expanding for some time, Bomengen said, but the need became apparent. “That was kind of our mindset for trying to get down there and help out with some of the shortages.”
Teton County also fields spillover from other communities. At Gros Ventre OB-GYN in Jackson, employees struggle to keep their heads above water, obstetrician Maura Lofaro said one August evening after hours from the office she shares with Dr. Shannon Roberts and nurse midwife Christina Kitchen.
When she started practicing in Jackson 26 years ago, “there were actually too many of us,” Lofaro said — about eight providers in obstetrics. And it was a crowded field for some time.
But in just the last couple years, she said, five providers stepped away from OB or cut their volume. And suddenly “it was like trying to drink from a firehose,” she said, “the volume was like, pouring in.”
St. John’s Hospital has helped by hiring a locums to help Gros Ventre’s providers handle the on-call delivery schedule, she said, and efforts are underway to recruit more doctors.
Meantime, “we have not turned any woman away from this office. We have made it work.”
That includes patients from Fremont, Sublette and Sweetwater counties. Lower-priority needs do get pushed off, Lofaro said. GYN patients calling for an annual exam won’t likely get seen for four to five months, for example.
The biggest challenge is not the patient volume — it’s retaining staff like nurses. “It’s just that we don’t have the support staff,” she said.
St. John’s Hospital plans to continue to support the staffing needs of its birth center into the future, Hospital CEO Jeff Sollis said during a hospital board meeting this summer.
“We will continue to be a resource for Fremont County families who are seeking high-quality obstetrical [care],” St. John’s Communications Officer Karen Connelly wrote to WyoFile in an email.
In early November, Jackson OB-GYN clinic Women’s Health and Family Care, which collaborated with Gros Ventre OB-GYN, announced it’s closing Dec. 15 “due to financial reasons.” In a letter to patients, the clinic said its doctors will continue to practice at other Jackson locations. “With the rising cost of overhead, including rent, labor, and supplies, our private practice is no longer sustainable,” the letter said.
Of all the births Siebersma has experienced over the years, it wasn’t necessarily the rare ones that were the most harrowing.
“The ones that are scary are when women had severe preeclampsia at 26 weeks, and there’s a snowstorm, and we can’t [fly] them out and we have to do a stat c-section, and we have a pound-and-a-half baby that the pediatricians are trying to stabilize in order to get him out,” he said.
And yet, part of what he found gratifying about delivering babies in rural Wyoming for so many years were the situations that tested his skills. “I like caring for really sick people,” he said.
Looking forward, Siebersma says he worries the eroding provider base will lead to less prenatal care and more of these scary scenarios. There is a lot of high risk in Fremont County, he noted: high levels of diabetes, high blood pressure and substance abuse. The hospital already sees women in labor who received no prenatal care, Siebersma added. Babies of mothers who do not get prenatal care are three times more likely to have a low birth weight and five times more likely to die than those born to mothers who do get care, according to the Office on Women’s Health.
“Ten years ago, I would have patients coming from Jackson or from Rock Springs or Casper, Dubois, Thermopolis, to deliver here,” Siebersma said. Now, that situation seems to have reversed.
It won’t be easy to undo.
“It’s a very complicated problem that didn’t just occur when I stopped seeing OB patients in January,” he said. “It’s been going on for a long time.”
Midwife Ommen called the situation “terrifying.”
“It makes me angry for the community,” she said. “I worry for them.”
This story was made with the support of the Center for Rural Strategies and Grist, and is part two in a series. Read part one of “Delivery Desert.” Part three will examine conditions at Lander’s hospital that critics say exacerbated the OB shortage.