Before fixing Wyoming’s maternal health gaps, agencies aim to understand them

Mandi Lew, a third-generation Wyomingite who grew up in Rock Springs, set out to deliver babies in southwestern Wyoming as a profession. Instead, she watched maternal health care options erode to such a degree that she took her skills elsewhere.

Lew delivered babies in Kemmerer before that birthing facility shut down in 2022. Nearby Rawlins also closed its OB ward around that time, “which is a huge gap,” she said. 

Lew also worked as a labor and delivery nurse at the Rock Springs hospital for 12 years, but when she became a nurse midwife, hospital bylaws would not permit her to practice without a supervising physician. That was untenable, she said. 

Lew still lives in Rock Springs, but now she commutes two hours to deliver babies at Layton Hospital in Utah.

“I went to school to do this, to support and help my community,” she said, but Wyoming wore her down. “I’m like, ‘OK, fine. I’ll just go deliver in Utah.’”

Lew, who still offers reproductive health care in Rock Springs, sits on the OB subcommittee of Gov. Mark Gordon’s Health Task Force, which aims to strengthen Wyoming’s health care workforce and examine ways to improve access for the state’s residents. In that capacity, she can provide a first-person perspective. 

If the erosion in care continues, Lew said, it will have grim consequences. Mothers will put off or forgo prenatal care, travel long distances or give birth in emergency rooms with nurses who aren’t trained in labor and delivery. “Our maternal mortality rate and infant mortality rate is going to significantly increase,” Lew said. 

“I don’t see it getting any better any time soon until we can make some changes,” Lew said. “Women deserve choices. Families deserve choices.”

Securing those choices is a challenge in this rural state. Over the course of WyoFile’s investigation into the state’s maternity care shortages, however, it’s become clear there is a will to find solutions. Medical professionals, government officials and moms want sufficient care for women undergoing what is one most fundamental of human experiences. 

But is there a way? 

That’s the question WyoFile probes in the final part of “Delivery Desert.” 

The problem

A dearth of maternal health care has made pregnancy and childbirth increasingly tricky in widening swaths of Wyoming. This is evident in Fremont County, where moms are opting to temporarily relocate to places like Denver and even the East Coast to deliver babies. It is evident in Rawlins, where families have to travel on Interstate 80, a notorious stretch of highway that closes frequently in the winter months, to deliver in Laramie. And it is evident in Teton County, where overflow patients from elsewhere in the state are putting a large demand on providers. 

In 2021, there were 6,235 resident births in Wyoming, according to the state health department. Of those, 76% were delivered in their mother’s county of residence; 12% delivered out of county and 11% delivered out of state. Big Horn and Sublette showed the largest percentages of out-of-county deliveries, at 83%. Neither are home to a birth facility. 

Rural maternity care seems to be in a self-perpetuating cycle, according to interviews. As labor and delivery units or OB offices close, obstetricians and midwives are more likely to depart the area, leaving remaining doctors vulnerable to burn-out and potential doctors less likely to see appeal in the positions that are available.

More than 15% of Wyoming women had no birthing hospital within 30 minutes of home in 2022, compared to 9.7% of women nationally, a report by the March of Dimes shows. Women who live farther from delivery hospitals are more likely to experience adverse medical outcomes. Babies are more likely to require a stay in the neonatal intensive care unit.  

Wyoming’s issues reflect national trends. At least 89 obstetric units closed in rural hospitals between 2015 and 2019, according to the American Hospital Association. Nationwide, 5% of counties have less maternity access than just two years ago, a March of Dimes Report found. 

Maternal mortality, meanwhile, more than doubled in the U.S. from from 1999 to 2019.

The Wyoming Department of Health released the state’s first maternal mortality report in May. It found that from 2018-2020, 13 women died during pregnancy or within one year after the end of their pregnancy. Mental health conditions were the most common cause of pregnancy-related deaths; drug or alcohol use was involved in all six, and all were deemed preventable. 

Fixes will have to be tailored to specific demographics and needs of Wyoming communities, according to interviews with community leaders and health policy experts. 

In Fremont County, where a single obstetrician and his midwife serve the general population of nearly 40,000, for example, those involved said better hospital accountability, more nurses, better succession planning for anticipated retirements and increasing public awareness could help. 

“I think it should be a concern for everybody,” County Commissioner Mike Jones said. 

Understanding the gaps 

The OB crunch is a frequent topic of conversation among members of the Wyoming Hospital Association, Vice President Josh Hannes said.

“It’s certainly a big concern,” he said, and it’s one that is complicated by hard choices. For example: Do hospitals continue to lose money on a service line because the community needs it? If so, how do they make ends meet?

“The money doesn’t fall from the sky for a hospital to operate,” he said, “but people expect it right? You’re sick, you’re injured. Whatever services you need, you want to go to your community hospital.” 

At the same time, Hannes said, “having a robust health care system and community is an economic driver. It’s an economic development issue.”

In other words, there are many strings woven into health care; as one frays, the entire structure begins to unravel. Each community’s fabric is unique. And so, Hannes said, “As we sit here today, I don’t know that there’s just one or two things that would work everywhere to really make a huge dent.”

Maternal health is also a conversation for Gordon’s Health Task Force, said Jen Davis, the governor’s senior policy advisor for health and human services. That’s why the task force created the OB subcommittee, which is trying to wrap its arms around the scope of OB needs and what barriers exist for expecting families and providers. 

There is “really a lot of exploratory conversation right now,” Davis said. “It’s a hard, complicated topic … because there’s a huge safety component around it. Childbirth is a dangerous thing.”

The subcommittee is preparing a survey to send to hospitals. The aim is to assess needs and existing services at a more granular level. With those needs elucidated, Davis said, the group can formulate policy recommendations as early as next year. 

A parallel effort could spring from the launch of Wyoming’s Maternal Health Innovation Program at the University of Wyoming, which recently won a $5.2 million federal grant. The program aims to reduce Wyoming’s maternal mortality by researching ways to improve clinical care, workforce development, data collection and community engagement surrounding maternal health. One facet is partnering with the state to create a maternal health strategic plan for Wyoming, according to UW. 

Workforce needs 

A major pinch point of rural health care is finding and keeping staff. 

“I think other states are in the same quandary that we are,” Davis said. “There’s just not enough providers to go around as it is, and then to try to recruit to Wyoming has always been challenging.”

Hannes said the scope of the problem calls for rethinking the qualities that draw workers.

“It’s not just pay anymore, right? It’s lifestyle,” he said. And attention must go beyond recruitment, he said, to “retention as the place where we can start to move the needle. So the people that we have here, how do we make them really sticky to our facilities and to the state?” 

The hospital association has policy recommendations.

“We’re really interested in seeing if we can get the Legislature to refund the nurse loan repayment program,” he said, referring to a health care professional loan repayment program lawmakers haven’t funded since 2018. Hannes believes Wyoming is missing out on medical staff; his group has heard anecdotes of physicians who wanted to be in Wyoming but went elsewhere because they would get their loans repaid.

Another idea, he said, is signaling to potential employees they will be safe in Wyoming. The WHA supports efforts to make assault, battery or threats of violence against health care workers their own crimes, he said. 

Other tools hospitals nationwide are testing in order to attract workers include offering more flexible scheduling and even signing bonuses. But because traveling nurses and doctors can find more lucrative work that might offer less onerous schedules, many in the medical field have shifted to that kind of position. 

Small gains, other opportunities

Wyoming’s Maternal Mortality Review is the result of a 2019 cross-state partnership with Utah. Because of that, it’s hard to ascertain long-term patterns of maternal mortality. But the program’s first report did come with recommendations for ways to prevent these deaths. They include improving access to behavioral health services, improved care coordination by providers, better access for provider training and bolstered community support services. 

One of the recommendations was granted: increasing the ability to access insurance longer into the postpartum period. 

“We at least took that first step to say, ‘yes, we’re going to extend postpartum Medicaid benefits from 60 days to 12 months,’” said Jen Simon, founder of Wyoming Women’s Action Network.

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Advocates have tried for many years to convince lawmakers to expand Medicaid, meanwhile. Wyoming is one of 10 states that hasn’t adopted expansion. 

Clinics and reproductive health advocates in states with poor maternal health outcomes have also worked to expand access to community-based doulas, something Simon is researching. Doulas are not medically trained, but they offer professional support for mothers before, during and after childbirth.

The state might rethink its reliance on doctors and do more to maximize the valuable skills doulas, midwives and others have to offer, Davis said. “Can we look at how we could leverage those professionals in a more meaningful way and build capacity within the state for looking at the workforce, because those might be easier to recruit or to train up in our state,” she said.

Tracy Rue of Lander has a different vision for supplementing maternal care in his hometown. His group, the Healthcare Partnership of Lander, is gathering resources to identify gaps, he said. But one of his goals is to open a women’s pavilion, which would directly impact OB services. 

The pavilion, a standalone facility for gynecological and maternal health care as well as deliveries, won’t come easily, he said. “We have to invest in ourselves, and this is going to be a big investment,” Rue said. 

Freestanding community birth centers often use a midwifery approach but partner with hospitals if complications arise. Rue is among Fremont County locals critical of the for-profit hospital model of companies like SageWest Healthcare, which operates the Lander and Riverton facilities. 

Another support lever could come in the form of transportation assistance. Wind River Family and Community Healthcare, for example, has a robust transportation system for transporting patients who need to see specialists. That clinic serves tribal patients.

Government’s role?

Wyoming’s health care challenges have long been a topic of state discussion, Rep. Loyd Larsen (R-Lander) said. But solving them can be tricky.

“We have to be careful that we demand health care be in every community,” Larsen said. “It’s not sustainable. And it’s the challenge that all rural states are having.”

There’s the philosophical question of the state’s obligation to fix these kinds of issues, he said. “Does the state have a role in ensuring that health care is provided to the citizens of the state? There’s a segment of the population who says, ‘Absolutely, they do.’ And there’s a segment of the population that says, ‘No, not at all.’” 

There are hospitals across Wyoming that are near financial distress, he noted. But lawmakers must also ask themselves: “Is it the state’s role to make sure that all those hospitals succeed?”

That being said, the Legislature approved $10 million in federal stimulus funds for the Riverton Hospital District’s effort to build a community-owned hospital — an effort prompted by what many claim is substandard service at the town’s investor-owned, for-profit hospital. SageWest Health Care, which operates the Riverton hospital, closed that facility’s labor and delivery ward in 2016. 

Another Legislature-supported effort is 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 tools 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 annually funds 20 seats for the University of Wyoming in the program. 

Since the start of the program in 1997, 194 students have earned medical degrees through WWAMI and completed residencies, according to UW. 

About 68% of graduates who completed residency, or 131, have returned to Wyoming to practice medicine. Of those 131 returnees, 102 remain in Wyoming practicing medicine — or 53% of graduates who completed residencies. 

Lawmakers can also hurt Wyoming’s health care landscape. And they’ve done harm, many argue, by passing a pair of abortion bans — though enforcement of the bans has been held up in the courts. 

Hannes’ association has not taken an official position on those bills. But based on what he has heard in legislative testimony and committee meetings, he said, “it sounds like maybe … there is a cooling effect” on providers wanting to practice in the state.

Simon also believes the bans’ message factors into where women of childbearing age want to live. Statistics on Wyoming’s so-called “brain drain” indicate that nearly twice as many women between the ages of 25-29 left the state than men, she said. 

All told, it reverberates “in terms of health care, but it also reverberates in terms of who stays in our communities, who’s working in the state, who’s helping to make the state continue to have cohesive and vibrant communities,” she said.

Conclusions

Back in Fremont County, Commissioner Jones has heard a lot of people say it’s time to form a hospital district. But, he said, the piecemeal way things are now — a for-profit hospital in Lander, a new hospital district in Riverton — complicate that prospect. 

“Rather than having a centralized approach, we have a fragmented approach,” he said. Still, he said, the district conversation may be inevitable. 

“I think the question that we’ll have to wrestle with is whether we go back to a public-funded hospital model,” Jones said. “I’m not saying I advocate that direction, but I don’t know that we can avoid it.”

Laura Gibbons, a family practitioner who provides obstetric care to tribal patients at Wind River Family and Community Healthcare, doesn’t think Fremont County’s maternal care challenges are futile. She herself delivered at SageWest Lander. 

“I think people have to care to fix it and it’s going to take that work, but I do think it’s fixable,” she said. One place to start is attracting more nurses to the hospital so support staff is in place, she said. 

One thing is certain, said Dr. Jan Siebersma, a Fremont County gynecologist who recently stepped away from delivering babies: The issue cannot be ignored or wished away.

“Babies come,” he said. “And when they come, you can’t stop them.”