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Mary Breckinridge (1881 - 1965)

By Gina Castlenovo, MSN, MPH, RN

  • Established the Frontier Nursing Service (FNS) in 1925 to provide professional health care in the Appalachian Mountains of eastern Kentucky, one of America's poorest and most isolated regions.

  • FNS, which has served as a model of rural health care delivery for the United States and the rest of the world, included a decentralized system of nurse-midwives visiting clients at their homes, district nursing centers, and a hospital serving an area of 700 square miles.

  • The FNS system lowered the maternal mortality rate in Leslie County, Kentucky, from the highest in the country to well below the national average.

  • FNS staff started the American Association of Nurse-Midwives, a precursor of the American College of Nurse-Midwives, in 1929 and the first American school of midwifery in New York in 1932.

  • The FNS School of Midwifery and Family Nursing, the longest continually operating nurse-midwifery program in the country, was established in 1939 in Hyden, Kentucky.

In the early 1900s, many women in rural areas of the United States had no access to health care. Most women gave birth to their children at home, with only the help of family members or neighbors. For every 100,000 live births, over 800 resulted in maternal death (vs. 7.7 per 100,000 in the US today), and 100 out of 1000 children died before their first birthday (vs. 7.2 per 1000 in the US today).1

Mary Breckinridge, born in 1881 to an influential Kentucky family, enjoyed a privileged childhood and education in the U.S. and Europe. Her father was the U.S. ambassador to Czar Nicholas II of Russia from 1894 to 1897.

In 1906, Breckinridge was widowed at age 26. Following the death of both her children at an early age, Breckinridge dedicated her life to improving the health of women and children. She became a registered nurse in 1910, at St. Luke's Hospital in New York. While working in France during World War I, she was exposed to new healthcare ideas: "After I had met British nurse-midwives, first in France and then on my visits to London, it grew upon me that nurse-midwifery was the logical response to the needs of the young child in rural America...My work would be for them.2"

After the war, Breckinridge studied public health nursing at Columbia University. She decided to tackle the health problems of eastern Kentucky, an area of few roads and no physicians, thinking that if her plans succeeded in such a poor, inaccessible area, they could work anywhere. Traveling on horseback, she surveyed families about their health needs and local lay-midwives about birth practices. She found that women lacked prenatal care and gave birth to an average of nine children, primarily attended by self-taught lay midwives, farmers' wives who relied on folklore and invasive practices.3

Breckinridge saw high maternal mortality and came to believe that children's healthcare should begin in the prenatal period, focusing on birth and a child's first years. She returned to London to become a certified nurse-midwife. She then visited Scotland to observe the work of a community midwifery system serving poor, rural areas; its decentralized structure served as a model for the Frontier Nursing Service. Returning to Kentucky in 1925, Breckinridge began the work that would introduce a new type of rural health care system in the United States.

The Frontier Nursing Service (FNS) was established in 1925 as a private charitable organization serving an area of about 700 square miles in southeastern Kentucky. Through her influential connections and speaking engagements, Breckinridge raised over $6 million dollars to support the organization. The staff was initially composed of nurse-midwives trained in England. They traveled on horseback and on foot to provide quality prenatal and childbirth care in the clients' own homes, functioning as both midwives and family nurses. Clients could pay the low fees in money or goods, and no one was turned away.4 In the area served, both maternal and infant mortality rates decreased dramatically.

FNS logoSince 1925, the FNS has registered over 64,000 patients, and in its first 50 years, it "delivered 17,053 babies with only 11 maternal deaths.5" An FNS-trained nurse-midwife began the first American school of midwifery in New York in 1932, and the FNS founded its own school in Hyden, Kentucky, in 1939.6 Breckinridge ran the Frontier Nursing Service until her death in 1965.

Today, the FNS still serves southeastern Kentucky, with a hospital in Hyden, four rural health clinics, a home health agency, and the FNS School of Midwifery and Family Nursing.7 People have come from around the world to study this model of rural health and social service delivery.

The American College of Nurse Midwives recognizes Breckinridge as "the first to bring nurse-midwifery to the United States" and the Frontier School of Midwifery and Family Nursing as "a leader in nurse-midwifery in the United States and a tribute to the accomplishments of Mary Breckinridge and her contemporaries.8" In 1982, Breckinridge was inducted into the American Nurses Association's Hall of Fame for her contributions to the nursing profession in women's health, community and family nursing, and rural health care delivery.

See the article: "Horseback-riding nurses and their courage and grit in Appalachia of the 1930s" published in the Washington Post April 25, 2020.

2. Breckinridge, Mary. (1952). Wide neighborhoods, a story of the frontier nursing service. Lexington: The University Press of Kentucky, cited in Deloughery, G. (1998). Issues and trends in nursing, 3rd Ed. St. Louis: Mosby; p. 353.

3. United States Department of the Interior, National Register of Historic Places. History of frontier nursing service. Accessed: February 19, 2003.

4. Kentucky Tales. Angel on horseback: Mary Breckinridge. Accessed: February 19, 2003.

5. United States Department of the Interior, National Register of Historic Places. History of frontier nursing service. Accessed: February 19, 2003.

6. American Nurses Association. Hall of Fame: Mary Breckinridge. Accessed: February 19, 2003.

7. Frontier Nursing Service. Mary Breckinridge healthcare. Accessed: February 19, 2003.

8. American College of Nurse Midwives. A brief history of nurse-midwifery in the U.S. Accessed: March 20, 2003.

Also see Stamp on History and the United States Post Office official stamp page.

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Last updated April 2020.

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