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The mountain midwives

11 March, 2014

The mountain midwives

In the mid-1920s, an American midwife recruited young British nurses for a pioneering service in the Kentucky mountains. Chris Holme shares their story of rugged terrain, horseback and births.


Midwives magazine: Issue 2 :: 2014


Call the Midwife has proved to be one the most popular dramas for BBC TV in a decade. 

It is based on the books by Jennifer Worth, recalling her experiences as a midwife in London’s East End in the 1950s. She was prompted to write them because midwives were not represented at all in literature, never mind television or film.

Thirty years earlier, there was another band of exceptional women. But there was no cycling around the crowded East End back streets for them – they rode on horseback across the wild rugged trails of the Appalachian Mountains. These were the nurse-midwives of the Frontier Nursing Service (FNS).

Midwifery was not then recognised as a profession in the US. Native American, African-American and European immigrants had their own traditions of birth attendants, often disparagingly characterised as ‘granny’ midwives, whose practice was founded on superstition or ignorance.

Unlike in Europe, there were no midwifery schools – the notion invoked fierce hostility from doctors – and, by the 1920s, US women were twice as likely to die in childbirth as those in England. 

Mary Breckinridge sought to change all that. Born into a rich and influential Southern family in the US, she lost both of her children before they reached five. She trained as a midwife in Woolwich, London.

Her ambition was to establish an effective nursing and midwifery service in rural Kentucky. The model she chose was the Highlands and Island Medical Service (HIMS) in Scotland.

HIMS was a unique social experiment – a state-funded, comprehensive health service established in 1913. It was designed to meet the needs of the crofting counties, which did not have the national insurance scheme that workers had in the rest of the UK.

In 1924, Mary ventured to Scotland to meet the midwives, nurses, doctors and administrators. It proved an epiphany.

She developed the concept of the nurse-midwife – providing not only care around births but also public health nursing looking after entire families. It was something of a revolution, proclaimed adverts in British newspapers:
Attention nurse graduates – with a sense of adventure! Your own horse, your own dog, and a thousand miles of Kentucky mountains. Join my nurse brigade and help save children’s lives. Write to M Breckinridge, Kentucky, USA.

Frontier life
Trainee midwife Betty Lester heard about the advert from an American colleague at the General Lying-in Hospital in York Road, London. Like so many of her generation, she had lost her sweetheart in World War One and both her parents were dead. What did she have to lose? Her supervisors were horrified at the prospect.

Undaunted, Betty was seasick for most of the voyage to New York and exhausted by a long train journey, which deposited her at a railroad station in Hazard – a small town in the middle of nowhere. ‘It was then I began to wonder what I had done,’ she later mused. But this was just the start – she still had a perilous horse ride to Hyden, some 20 miles away.

Annie Mackinnon from Skye was another volunteer. Unusually for a nurse, she had been awarded the Croix de Guerre for conspicuous bravery, for continuing to care for the sick and wounded under enemy fire during the retreat from Aisne in the early summer of 1918.

The Frontier nurses developed a close, sisterly camaraderie. Each had a nickname. Annie inevitably became ‘Mac’. Her Irish colleague Hannah O’Driscoll from Skibboreen was ‘Nancy’. Another arrival was ‘Stevie’ Stevenson from Clydebank.

Each nurse wore an FNS cap and had a blouson in confederate grey. They carried necessary gear for nursing and delivery, plus snakebite serums in large saddlebags as they went about their work.

For some, the frontier life and Breckinridge’s domineering personality proved too much and they left. For others, it was an intoxicating challenge offering the freedom to live their own life and practise their profession without the stifling restriction and drudgery they left behind in the UK.

But the work could be unrelenting and dangerous. Midwives occasionally had to treat gunshot wounds resulting from feuds over bootleg whiskey. Their horses could be unpredictable and covering the terrain was inherently hazardous. Mary Breckinridge herself broke her back in a fall from her horse in 1931.

Changing times
The first to part from the group was Nancy. She had ridden out to care for a mother and stayed with her despite being ill herself. By the time she got back, Nancy’s appendix had ruptured. She was only 35 when she died.

Nancy was deeply mourned by her friends and colleagues, and hundreds of grieving patients lined the route of her funeral. But the FNS carried on and survived drought, the Great Depression and a constant battle for funding from wealthy philanthropists.

The service showed that it was effective through innovative epidemiology, long before this term appeared in medical textbooks. Meticulous population studies were carried out before it started and scrupulous records were kept of each birth, postnatal care and vaccination programmes.

An external audit of its first five years demonstrated astonishing success. It was carried out by the vice president of the Metropolitan Life Assurance Company in New York, and the foremost health statistician of his generation, Louis Dublin. In 1932, he concluded that, if the same nurse-midwife service was available across the US, every year there would be 10,000 fewer mothers dying and 30,000 more children alive after the first month of life.

The FNS faced another crisis seven years later, as the UK midwives decided to go back and serve in the war. Without them, the FNS faced extinction, so it opted to set up its own training school. It flourished and still survives today as the Frontier Nursing University.

After the war, both Annie and Betty considered their options. Which would it be – the type of practice in London that Jennifer Worth was about to enter or back to the wild frontier? Kentucky won – they came back to spend the rest of their lives with the FNS.

Chris Holme
Former Reuters Foundation fellow in medical journalism at Green College, Oxford

Chris has written extensively about the mountain midwives on his blog at the History Company.




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