UK-US midwifery: a special relationship

By Chris Holme on 03 September 2018 Midwives Magazine Midwifery Neonatal Death

Chris Holme looks at how the transatlantic bond in midwifery services was forged on the American frontier, and how maternal mortality rates in the UK and US have diverged since. 

Winston Churchill first spoke of the ‘special relationship’ between the UK and US in 1946. But it is pre-dated by a deeper one forged by midwives and nurses. On 26 June 1928, Scotland’s chief medical officer Sir Leslie Mackenzie, 66, and his wife Helen formally opened a new hospital.

But this was 4000 miles away in the Appalachian Mountains – an area so remote that there were no roads and travel was on horseback. Neither of the Mackenzies could ride, so a buckboard was brought in for the journey from the railroad. They trundled 22 miles over rough tracks, teetering over precipices in a violent rainstorm, and fording the swollen Kentucky River.

They came because of their extraordinarily close bond with Mary Breckinridge, founder of the Frontier Nursing Service (FNS), who wanted them to open the first FSN hospital on Thousandsticks Mountain in Hyden, Kentucky.

That bond was based on a shared passion to help the poorest mothers and children.

Born into an influential family from the southern US, Mary had trained as a nurse in New York and as a midwife at Woolwich in London – there was no midwifery training in the US. She was appalled that more American women had died in childbirth than American men killed in all wars (Breckinridge, 1927). Maternal mortality rates were twice those in the UK (Breckinridge, 1927), which was served by well-trained Queen’s Nurses.

She found a model for her scheme in the Highlands and Islands Medical Service (HIMS) that Sir Leslie helped establish in 1913.

Cultural crossover

The Mackenzies had served on various royal commissions to promote the health and welfare of poor children. They were close friends of Elsie Inglis, the pioneer female doctor and tireless suffragist who set up the Scottish Women’s Hospitals for Foreign Service to provide all-female-staffed hospitals in World War One. But her real life’s work was with poor women and children just off the now-fashionable Royal Mile in Edinburgh.

The Mackenzies rolled out the red carpet for Breckinridge when she came to Scotland in 1924. Sir Leslie was medical member for the Scottish Board of Health – the equivalent of chief medical officer now – and his letter of introduction for Mary’s tour north opened many doors for her on a journey that changed her life. She was overwhelmed by the warmth and kindness of the welcome, and the professionalism of the midwives and nurses she met, particularly in the Hebrides.

‘Sometimes an experience is so deeply creative that you respond to it with everything that you have, not only in retrospect but at the time. When I went to Scotland in mid-August of 1924... I knew that weeks of enchantment lay ahead of me, but I could not know until it happened what it would be like to enter a strange country and feel at once that I had come home,’ she later wrote.

Breckinridge found little poverty in the islands except for children on Colonsay who lacked warm clothing. Back in Edinburgh, she bought them jumpers from Princes Street. She also took copious notes – 11,000 words of her meetings and experiences.

The Mackenzies helped again when Breckinridge needed a leader for an epidemiological survey in Kentucky. They recommended Williamina Bertram Ireland, a former colleague who had also done field work in the Hebrides, before heading to the US to work for the Committee on Maternal Health in New York.

Williamina had two further essential qualities: she could ride a horse and take a nickname. As recounted in a previous article (Midwives, Spring 2014), the FNS gave nicknames to each new member of staff, mostly recruited from the UK. She became ‘Ireland from Scotland’ and Annie Mackinnon, from Skye, inevitably became ‘Mac’.

There were other transatlantic links. Yale’s School of Nursing was directly modelled on Rebecca Strong’s training at Glasgow Royal Infirmary. Elsie Inglis had plans for a new maternity hospital, based on one she had seen at Muskegon, Michigan, on holiday in 1913.

In Canada, the Newfoundland Cottage Hospital System was inspired by the HIMS, and Elsie Stephenson drew on her time at Toronto University to develop graduate nursing at Edinburgh.

What made the Kentucky relationship so special were the deep personal links. Sir Leslie went into lyrical overdrive when writing about his visit in The Lancet: ‘It is a story full of adventure, sacrifice, passionate enthusiasm and splendid initiative... The invitation was a call of the Highlands to the Highlands. It is a symbol of kinship in feeling and outlook. It is the lightning spark that reveals the essential unity of our culture.’

A fine legacy?

Helen Mackenzie went on a lecture tour on her return, encouraging adventurous nurses to join the FNS. Already Lady Mackenzie as Sir Leslie’s wife, she was – highly unusually for the time – made a dame in her own right for her contributions to child health.

These links continue today, with UK cities adopting the US Family Nurse Partnership. The frontier spirit lives on in Kentucky: the Frontier Nursing University was established in 1939, and the title of Queen’s Nurse was reinstated, in England in 2007 and Scotland in 2017.

So is there a glowing legacy from this special relationship? Not quite. Parity between the US and Europe for maternal mortality had largely been achieved over seven decades. However, this trend has been reversed since 2000 in the US, which despite far higher health spending, records far higher maternal mortality rates than other developed countries (Unicef, 2017).

The reasons are complex: US midwifery still faces a struggle for identity as a profession, there are stark disparities between ethnic groups, and lack of continuity of care is linked to poorer outcomes (see below).

One thing’s for sure: 90 years on, both Breckinridge and the Mackenzies would be shouting about it. Very loudly.

Today’s UK-US maternal mortality gap

  • 8.9 women for every 100,000 live births die from complications of pregnancy or childbirth in the UK, compared with 25.1 women in the US. ProPublica looks at the reasons here
  • ProPublica and National Public Radio launched an award-winning investigation into US maternal care and preventable deaths, Lost mothershere

Chris Holme is a former Reuters Foundation fellow in medical journalism.


Breckinridge M. (1927) The nurse-midwife – a pioneer. American Journal of Public Health 17(11): 1147-51.

See: (accessed 14 August 2018).

Unicef. (2017) Maternal mortality – February 2017. See: 14 August 2018).