Maternity is the young woman’s battlefield,” wrote Mary Breckinridge in 1927. “It is more dangerous, more painful, more mutilating than war, and as inexorable as all the laws of God.” Breckinridge’s theater of operations was Leslie County, Ky., deep in the heart of the Cumberland Mountains. There were no paved roads in the county then, and no railroads. The Middle Fork of the Kentucky River and its branches snaked through tiny communities with names like Cutshin, Hell for Certain and Tousandsticks. Logging and subsistence farming kept body and soul together for most folks. The coal boom that was transforming neighboring counties had not reached Leslie, where the only town of any size was the county seat of Hyden, population 300 or so. In this most unlikely place, Mary Breckinridge made her stand for maternal and child healthcare in rural America by founding the Frontier Nursing Service in 1925.

For every 1,000 live births in the United States in the early 20th century, approximately 100 babies died within the first year. The maternal mortality rate was the highest in the developed world, nearly twice that recorded in England at the time. In rural areas like Leslie County—described by Appalachian chronicler Harry Caudill as the “most primitive” in the Cumberland Plateau—the numbers tended to be higher.

Professional medical care was practically nonexistent in eastern Kentucky’s hills and hollows. “Our parents learned very early in life how to doctor their children,” remembered Leslie County resident Laura Day Hogg in a 1979 interview. “My mother used to go out and gather a lot of herbs…and have them to make teas in the winter, cough syrups…and things to break up colds with.” Most births were attended by midwives, “granny women” who’d learned the trade from their mothers and grandmothers or by hard experience. Tough they had little formal education and were often illiterate, midwives were respected members of their communities and their home remedies were familiar parts of the birthing process. Catnip, ginger and pepper teas were used to ease labor pain. If the new mother started to hemorrhage, the midwife might administer tea made from bark taken from the north side of a black gum tree steeped with bark from a sweet apple tree. An ax placed under the bed with the blade up was thought to stem the flow. If all else failed, divine intervention could be called on by reciting Bible verses, particularly Ezekiel 16:6: “And when I passed by thee, and saw thee polluted in thine own blood, I said unto thee…Live.” Newborns were often dosed with castor oil and catnip tea, their navels greased with lard or castor oil and dressed with a scorched rag.

Mary Breckinridge’s genteel background was worlds away from impoverished Appalachia. Born in Memphis in 1881, she was the granddaughter of Kentucky’s own John C. Breckinridge—vice president to James Buchanan, 1860 presidential contender, Confederate general and secretary of war to Jefferson Davis. Her father, Clifton, was a Confederate veteran who later represented Arkansas in the U.S. House before being appointed minister to St. Petersburg. Mary grew up in privilege, attending boarding schools in Switzerland and Connecticut and traveling often among her extended family in the South. But she also knew her share of sorrow. Her first husband died of appendicitis, and Breckinridge resolved to become a nurse, graduating from the prestigious St. Luke Hospital School of Nursing in New York in 1910. An unhappy second marriage ended in divorce after the deaths of her two children—a daughter who died in 1916 just hours after her birth and a son who died in 1918 at age 4.

Mournful but determined, Breckinridge headed overseas and joined the American Committee for Devastated France, a group of volunteers organized by Anne Morgan, daughter of financier J.P. Morgan, to help French refugees of World War I. Breckinridge was deeply touched by the children whose lives had been upended by brutality and want, but she longed to return home to work for the welfare of American children. When she learned of a British program that trained women as nurse-midwives to provide vital medical care in areas where doctors and hospitals were scarce, Breckinridge found what she called “the logical response to the needs of the young child in rural America.” After studying midwifery at the British Hospital for Mothers and Babies and spending time in Scotland observing the work of the Highlands and Islands Medical and Nursing Service, Breckinridge was ready to implement a similar healthcare delivery system in the remote mountains of eastern Kentucky. If her idea worked there, she reasoned, it could work anywhere in the world.

“The Kentucky mountaineer has been written up and talked about as though he were a special kind of Homo sapiens.” Breckinridge wrote in her 1952 autobiography, Wide Neighborhoods. “The picture that people from beyond the mountains hold of [him] is uniform. They see a lean man with a gun tending his moonshine still, while his wife and fifteen children clutter his one-room log cabin by night and plow his hillside by day. If he speaks at all before shooting, it will be in words too archaic for comprehension.”

There was some truth to this notion of Appalachians as “our contemporary ancestors”—a phrase coined by William Goodell Frost in his 1899 book about the distinct culture of the Southern mountains. Folkways and language dating back to the earliest mountain settlers, many of them immigrants from the British Isles, had been preserved by the region’s isolation. When industrial logging and coal mining began making inroads in the late 19th century, outsiders often looked on Appalachians as quaint throwbacks to some purer time.

Breckinridge regularly made reference to this “old American stock,” descendants of ancient Anglo-Saxons who “have only recently emerged from pioneer days,” in her publicity and fundraising efforts for the Frontier Nursing Service. In an age of rapid social change, with an influx of millions of immigrants and a resurgence of the Ku Klux Klan, potential donors responded to the idea that they were helping “worthy” Americans in need. This nativist attitude was common to Progressive reformers— often upper-class, white Protestant women—of the time, and in Leslie County, the numbers largely backed up Breckinridge’s claims: The 1920 census recorded 9,998 of the county’s 10,097 residents as native-born whites.

In 1925 Breckinridge won the support of the state health commissioner to bring modern healthcare to Leslie County. She recruited two New York nurses who’d received midwifery training in England, Freda Caffin and Edna Rockstroh, to join her in Hyden, and she put her money where her mouth was. “I promised to underwrite the work for the first three years and meet whatever deficits were incurred,” Breckinridge recalled. “I didn’t want to do this, because it would have to be done out of my capital and I liked having an independent income. But [there was] no other way to get started. . . .It was just one of those things.” They set up a hospital, the county’s first, in “the only vacant house in Hyden. This was a two-story dwelling in bad repair…but there was room for a dispensary and a barn for the horses. We had no plumbing but the outside conveniences were decent, and we had a clean well.” By 1930 the Frontier Nursing Service had established nine county districts and set up six satellite clinics. Two nurses were assigned to each district, the idea being that care should never be more than an hour away by horseback.

Some mountaineers initially distrusted the newcomers. Because no training program for nurse-midwives existed in the United States, Breckinridge recruited nurses from England and Scotland. Nellie Asher, whose first child was the first baby delivered by a Frontier Nurse in September 1925, remembered hearing gossip that “the nurses from England would kill the little babies.” British nurse Betty Lester, who arrived in Hyden in 1928, attributed the rumors to fear of the unknown. The nurses were strangers, she said, young, unmarried women who had no children of their own. What could they possibly know about birthing babies in hardscrabble Kentucky? In time the rumors died down as word began to circulate of the nurses’ success in delivering healthy babies in difficult circumstances. A local advisory committee of prominent county residents—including the sheriff, a pastor, the school superintendent, the editor of the county newspaper and a bonafide war hero, Willie Sandlin, whose exploits in Europe rivaled those of fellow Kentuckian Alvin York—also helped legitimize the nursing service.

The Frontier Nurses made regular rounds, introducing themselves and their services. Sherman Wooten, one of dozens of participants in a University of Kentucky oral history project that documented the impact of the Frontier Nursing Service, remembered the impression the nurses made. Wooten, born on Cutshin Creek in 1910, said, “There was a couple of public health nurses” in Leslie. “We never did see any of them anyway on Hell for Certain or Bull Creek or anywhere down in there. . . .After Miss Breckinridge was here for a short period of time, she put these centers out in parts of the county. . . .The community would get together and build up a small little house” to serve as a clinic.

Frontier Nurses encouraged expectant mothers to get regular prenatal checkups, an idea just then gaining traction in professional medicine and one that had been unheard of in the mountains. Breckinridge said that “the midwife never leaves her patient [once labor begins]…staying 2 days and nights in the home if need be. Because we have been trained in midwifery, we are able to see the normal cases through and also to recognize the abnormal and get medical aid…carrying on with courage until it comes.” And to prove—to the medical community and to outside supporters of the program—that this level of care made a significant difference, Breckinridge insisted on meticulous record-keeping. No mothers died in the first 1,000 live births attended by Frontier Nurses; the national maternal death rate was 5.2 per thousand. In 1932 the Metropolitan Life Insurance Company reviewed the nursing service records and concluded that its work “safeguards the life of mother and babe. If such a service were available to the women of the country generally, there would be a saving of 10,000 mothers’ lives a year…30,000 less stillbirths and 30,000 children alive at the end of the first month of life.”

For their services, the Frontier Nurses charged $5 for prenatal care, delivery and 10 days of postpartum care. A fee of $1 per family per year paid for general medical care and vaccinations against outbreaks of such deadly diseases as typhoid and diphtheria. With little cash on hand—the average yearly family income in 1932 was $416.50, with less than half of that received in cash—mountaineers often paid their bills with produce, hay for the horses or manual labor.

By the mid-1930s, nurses on horseback were a familiar sight, dressed in blue-gray uniform coats, breeches, white shirts, ties, caps and knee-high riding boots, their saddlebags packed full of supplies for almost any medical emergency. When mountain children asked where babies came from they were told, “The nurses bring them in their saddlebags.” It was an image that Breckinridge used to great effect in the publicity campaigns she engineered to attract both donations and staff. If some county residents bristled at national press that portrayed their home as a backward backwater, they largely spared Breckinridge and the nurses. “We don’t like to see the worst possible conditions that can be described and exaggerated peddled upon as the fruits and products of Leslie County,” wrote one resident to the local newspaper, but “we…honor Mrs. Breckinridge for her work in our behalf.” A 1937 Life story praised the scope of that work: 3,000 babies delivered with no maternal deaths; 90,000 inoculations and vaccines administered; wells chlorinated across a 700-square-mile area; $1 million raised from private donors.

There was something romantic about the notion of a woman riding alone through the hills, delivering babies and hope. “Any hour may come the call,” wrote Breckinridge in the American Journal of Public Health in 1927, from a man sent to fetch help for his laboring wife: “‘Hey, woman, my woman is needing you,’ and the nurse-midwife…gets her lantern and rides of.” But the work of the nursing service depended on more than just medical staff. A sense of adventure and a promise of usefulness drove many young women from privileged backgrounds to join the service as couriers. Couriers cared for the horses (there were no veterinarians nearby), kept the riding tack in good repair, delivered supplies to the outlying clinics and sometimes accompanied the nurses on their rounds. Dorothy Caldwell, a doctor’s daughter from Cincinnati, became a courier in 1935. It was a way of life that most young women just out of school could never imagine. “We were going into strange territory with the use of nothing but a map,” Caldwell said in 1979. “We had a map of the county that showed the creeks, and the creeks were the roads. Anytime you met somebody, which was very seldom, you questioned them about where you were, were you on the right road. Everybody was always very helpful… very friendly.” These “horse-riding debutantes,” as one historian described them, were also walking recruiting posters for the Frontier Nursing Service, spreading the word to their affluent communities back home.

Breckinridge was a masterful networker. As a nurse with the American Committee for Devastated France in 1920, she wrote to her mother about the lack of milk for the refugees. “If I could give right now a goat to every family that has a baby, I think we could go far toward saving many that are dying. . . . I wish I had a thousand goats right now. I wish I had fifty.” Her mother, Katherine, organized donations from family and friends across the country, and before long, the first shipment of goats arrived in France. Breckinridge called on similar connections to set up regional committees for the Frontier Nursing Service in cities such as New York, Detroit and Chicago. The committees, which included the likes of Eleanor Roosevelt and Clara Ford, wife of the automobile titan Henry Ford, provided a relatively steady income for the service. A cousin, Mary Marvin Breckinridge, was an accomplished photographer who shot many of the service’s early publicity images and even made a documentary film, The Forgotten Frontier, in 1931. (Marvin Breckinridge, as she chose to be called to distinguish herself from cousin Mary, went on to cover the London Blitz with Edward R. Murrow in November 1939, the first female reporter for the CBS World News Roundup.)

Always hands-on, Mary Breckinridge directed the Frontier Nursing Service until her death in 1965. In those 40 years, Frontier Nurses delivered 14,500 babies with only 11 maternal deaths and treated some 58,000 patients overall. If Breckinridge played up the romanticism, she never underestimated the difficulty of the work. And if she was sometimes hard to deal with—opinionated and headstrong, some of her colleagues called her—that was understandable. “I don’t guess she had time to be foolish,” Leslie County native Ed Morgan explained in 1978. “She was a person that wanted to get the job done.”

By almost any standard, the service was an unqualified success in bringing effective healthcare to an under-served area, and Breckinridge’s lasting contribution to public health was the establishment in 1939 of the Frontier Graduate School of Midwifery in Hyden, the first school of its kind in the United States. The school has remained in operation for 76 years and, as the Frontier Nursing University, it has trained thousands of nurses to provide midwifery and family care in remote areas around the world. The Frontier Nursing Service no longer makes house calls on horseback, but its work continues in the Mary Breckinridge Appalachian Regional Healthcare Hospital in Hyden, a small, critical access hospital designed to meet the immediate medical needs of rural residents. Ironically, its maternity ward closed in 2010, part of a national trend that critics complained severely limited healthcare options for rural Americans.

The spirit of the service, however, is alive and well as home births are once again on the rise. The Centers for Disease Control reported that the number of home births in the United States increased by 59 percent between 2004 and 2012, though it’s still an extremely small number of total births. The need for skilled nurse-midwives is likewise expected to increase for the foreseeable future. That’s exactly what Mary Breckinridge had in mind. The work that began in eastern Kentucky, she said in 1932, was “a training field for the extension of such work in other such communities. . . .Of on the lonely farmstead…the young mother faces her agony, that the hope of [her] nation may come into life. . . .For her we need the Frontier Nurses— new pioneers on old frontiers.”


Originally published in the June 2015 issue of American History. To subscribe, click here.