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The work of the Frontier Nursing Service (FNS) began in Leslie County, Kentucky in 1925 by the late Mrs. Mary Breckinridge, who remained its Director until her death in 1965. Mrs. Breckinridge decided, following the death of her two children, to devote her life to the health care of children in remote areas. She acquired her basic nursing education at St. Luke’s Hospital in New York City, and then served as volunteer with the American Committee for Devastated France following World War I. It was in France that Mrs. Breckinridge met a British nurse who was also a midwife and realized that the nurse-midwife had unique qualifications for work in rural, medically underserved areas.
“After I had met the 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 health care needs of the young child in rural America.”
“To meet the needs of the frontiersman’s child, you must begin before he is born and carry him through the hazards of childbirth. This means that the nurses who serve him must be qualified as midwives. They must be nurse-midwives.”
Upon completing her work in France, Mrs. Breckinridge studied midwifery at the British Hospital for Mothers and Babies in London and spent some time with the Highlands and Islands Medical and Nursing Service in Scotland to observe the kind of decentralized health care that would become the model for the FNS. After the war, Breckinridge studied Public Health Nursing at Columbia University. She formulated two goals: improving the health of children and pioneering a system of rural healthcare that could serve as a model for healthcare systems serving the most remote regions of the world.
She chose Eastern Kentucky for her demonstration project, an area with few roads and no physicians. She felt that if the work she had in mind could be done here, it could be duplicated anywhere. In the summer of 1923, traveling on horseback, Breckinridge initiated a study of the health needs of the people of Leslie, Clay, Perry and Harlan counties. She rode over 700 miles interviewing families and lay midwives. She found that women lacked prenatal care and gave birth to an average of nine children, primarily attended by self-taught midwives. She saw high rates of maternal mortality and came to believe that children’s healthcare must begin before birth with care of the mother and follow that care throughout childhood while including care for the entire family. Of the area she had chosen, and her ideas about rural health care, Mrs. Breckinridge wrote:
“In 1925 the territory in the Kentucky mountains, where Frontier Nursing Service began its field of operations, was a vast forested area inhabited by some 10,000 people. There was no motor road within 60 miles in any direction. Horseback and mule team were the only modes of travel. Brought-on supplies came from distant railroad points and took from two to five days to haul in. U.S. mail sacks traveled in little carts or slung across the backs of horses and mules. There was not in this whole area a single licensed physician, not one.”
“Even after his birth the young child is not an isolated individual. His care not only means the care of his mother before, during and after his birth, but the care of his whole family as well. Bedside nursing of the sick in their homes is as essential in rural areas as in the Visiting Nurse Associations of cities. It means including the whole family, because the young child is part of his family. Health teaching must also be on a family basis—in the homes.”
Thus reasoning, the Frontier Nursing Service became the first organization in America to use nurses qualified as midwives. Using the Highlands concept the nurses were also expected to serve as public health nurses. The organization was originally known as the Kentucky Committee for Mothers and Babies and later named the Frontier Nursing Service.
Between 1925 and 1930, the FNS grew rapidly. The first clinic was opened in Hyden in 1925 by Mrs. Breckinridge with the help of two nurses. By Christmas of that year, Mrs. Breckinridge had built the log house at Wendover that was to be her home for forty years and which was the beginning of the complex which has served for more than 80 years as the administrative headquarters of the FNS. The Hyden Hospital and Health Center was completed in 1928 and, responding to the demand from local citizens for accessible nursing care, nine outpost nursing centers were built in Leslie County and the Red Bird River section of Clay County.
Mrs. Breckinridge believed that she must involve the community in order to be successful. Her intention was to work through the community, not for the community. She developed local committees to provide assistance and advice for the hospital and for each clinic.
Mary Breckinridge initially funded the service through her personal funds. There was no state or federal funding available to help with the project. When her personal funds were exhausted, she garnered support through her family connections and friends. Mrs. Breckinridge spent much of her time outside the mountains in the early years, developing the base of financial support that survived the depression and enabled the FNS to carry on in the ensuing years. She organized support committees of philanthropic individuals in many large cities such as Boston, Washington, DC, Philadelphia, Louisville and Lexington. Through the devoted work of the members of these committees, FNS survived through many difficult times.
The Service was a decentralized healthcare system with the hospital at the center and the out post/nursing clinics located within a five-mile ride on horseback. The region served by the FNS was divided into nine districts with 6 outpost-nursing centers. These centers were staffed by nurse-midwives, who held clinics, made rounds on horseback providing home care, and went to the homes to attend births. They served an average of 250 families per outpost. They also held immunization clinics at one room schools and provided advice regarding sanitization of wells and outhouses. They made arrangements for high-risk patients to be seen at Hyden Hospital. The hospital offered nurses and a physician who could perform surgeries. They also had visiting doctors who would hold specialty clinics such as gynecology, eye, ears, nose and throat and orthopedics. A system of referrals was developed to ensure that FNS patients could get specialist care beyond the mountains which could not be provided by the Service’s own professional staff—a system which continues today.
A major challenge of providing care in the rural mountainous region was communication. Early on there was nothing except once a day mail. Later there was an unreliable phone service. To deal with this and the needs of getting supplies to the outpost clinics as well as helping with all the work that had to be accomplished each day, Mary Breckinridge started a volunteer service and called the participants Couriers. The Couriers were initially recruited from Mrs. Breckinridge’s many family and friends. Most were young women seeking adventure and an opportunity to serve mankind. Couriers spent much of their days in the saddle carrying news and supplies between the many clinics and the hospital. They guided visitors and transported patients when necessary. They also had the charge to care for all the horses of the Service.
The health care system established by Mary Breckinridge worked so well that that there was an immediate decrease in infant and maternal mortality. The FNS kept careful statistics and evaluated its progress after every thousand births. They were tabulated by the Metropolitan Life Insurance Company. The report on the first 1000 births stated the following:
The study shows conclusively what has in fact been shown before, that the type of service rendered by the Frontier Nurses safeguards the life of mother and babe. If such service were available to the women of the country generally, there would be a saving of 10,000 mothers’ lives per year in the United States, there would be 30,000 less still births and 30,000 more children alive at the end of the first month of life. The study demonstrates that the first need today is to train a large body of nurse-midwives, competent to carry out the routines that have been established both in the Frontier Nursing Service and in other places where good obstetrical care is available.
By 1958, the FNS nurse-midwives had attended over 10,000 births. All maternal and infant outcome statistics for FNS's first thirty years of operation (1925-1954) were better than for the country as a whole. The biggest differences were in the maternal mortality rate (9.1 per 10,000 births for FNS, compared with 34 per 10,000 births for the United States as a whole) and low birth weight (3.8 percent for FNS, compared with 7.6 percent for the country).
When World War II began in 1939, a number of the British staff wished to return to their homes as soon as they could be released. Under wartime conditions it was not possible to continue sending American nurses to Britain for midwifery training so the FNS put into immediate operation its dream of a graduate school of midwifery. The Frontier Graduate School of Midwifery admitted its first class in November 1939, and has been in continuous operation since that time. Graduates of the school have practiced their profession all over the United States and in many developing countries. In the late 1960s, the FNS recognized that as health care options became more complex, a broader based education was necessary for nurses to be able to provide comprehensive primary care to all family members. At this time the Frontier School developed the first certificate program to prepare family nurse practitioners (FNP). In 1970, the name of the School was changed to the Frontier School of Midwifery and Family Nursing (FSMFN) to reflect the addition of the FNP program.
In 1975, the Service completed and opened the modern, forty-bed Mary Breckinridge Hospital and Health Center. This hospital has served the health care needs of the people of Leslie County for the past 30 years and continues its operation today as a critical access hospital.
Over the ensuing years, there were many changes in the Southeastern KY region. The opening of roads brought an end to the era of nurse on horseback. But it did not bring an end to the caring philosophy of the FNS. Today the Service operates 5 federally designated rural health clinics, the critical access hospital, and a home health service. The Frontier School of Midwifery and Family Nursing is the largest school of midwifery in the United States. The School also offers programs for aspiring family nurse practitioners and women health care nurse practitioners. Programs are offered to students in remote and rural areas through distance education. Wendover continues as the administrative hub of the service. The original log cabin fondly called the Big House that was Mary Breckinridge’s home for over 40 years was honored as a National Historic Landmark in 1991 and became a Bed and Breakfast in 2001. The Courier program today is a much sought after internship program. Students come and shadow nurse-midwives, nurse practitioners, physicians and help with the many day-to-day tasks of operating the Service.
The Service developed by Mary Breckinridge has provided excellent care to the people of Eastern KY for over 80 years as well as graduating over 1700 nurse-midwives and nurse practitioners who serve all over the world.
