Mary Breckinridge and the Frontier Nurses of Eastern Appalachia

Night had fallen.

The young woman secured the newborn in the leather saddle bag and began to navigate her horse deeper into the woods of Eastern Kentucky’s Appalachian Mountains. On a good night, the terrain was unstable, wet, rocky, with brambles and narrow winding passages, but tonight, there was a light rain, making it slippery and marshy, in places treacherous. She was undeterred and determined to reach her destination, Hyden Hospital, before the rain grew heavier and the baby’s breathing grew worse.

As she moved through the woods, keeping the horse’s gait measured, she had nothing but time and her thoughts. The road to this moment had been long. It was one her parents didn’t imagine for their daughter. But, from a young age, Mary Carson Breckinridge was her own person: charismatic, iron-willed, and eager to carve out a life on her terms.

Born in 1881 in Memphis, TN to a politically influential family with a history of statesmen, members of Congress, ambassadors, and her grandfather, John Breckinridge, a U.S. vice-president, Mary enjoyed a privileged upbringing. Her father was the U.S. ambassador to Czar Nicholas II of Russia, enabling him to give her a sophisticated education that included private tutors, finishing school, travel, and attendance at historic political affairs—in the Spring of 1896, he took the family to the Coronation  of the Czar, a trip that altered the course of Mary’s life.

In the Kremlin’s Dormition Cathedral, 15 year-old Mary watched as Nicholas crowned himself with the Great Imperial Crown of Russia, a magnificent piece of handiwork adorned with 4,936 diamonds that glistened in the grand cathedral like tiny pinpoints of starlight. But, unlike the tens of thousands who turned out to celebrate, young Mary wasn’t impressed.

Instead, something else had captivated her: the foundling asylum she had visited the previous day with her mother. There, she saw rows and rows of cribs full of rescued babies, some came from the streets of Moscow and others were left at the asylum door. She held them, stroking their pale faces, glimpsing in them the bitterness and blight of poverty and shame. Deep inside she felt a maternal ache to keep them safe. The feeling never left her.

As the years passed, her ambitions grew, and she longed to forge her own pathway and establish herself like the men in her family, but the turn of the 20th century wanted little to do with women and their dreams: Women became wives then mothers. Mary would be no exception.

Her parents disapproved of sending girls to college, so she didn’t go. Instead, after high school, she spent hours thinking of ways to skirt the cultural norms; she wanted a career and a marriage and children. There was no way.

In 1904, at 23, she willingly chose to follow the traditional expectations of society: she married a young lawyer and moved to Arkansas; two years later, he died from appendicitis. Mary sought consolation at a girl’s settlement school in North Carolina, where she got her first glimpse of charitable work. There she witnessed a child die of typhoid fever. In response, she entered St Luke’s Hospital School of Nursing in New York City–nursing allowed her to have a career and appease the maternal instinct that gnawed at her. Three years later, she graduated as a Registered Nurse.

But her career would be short-lived.

In 1912, a second marriage brought her back to Arkansas where her husband was president of Crescent College and Conservatory for Young Women. There, Mary taught French and Hygiene until her son was born in 1914; then she retired and had plans to be a wife and mother, something she, like the women of her time, revered. Two years, later, she gave birth to a baby girl, Polly, who died within hours. Sadly, the tragedies would continue. In January 1918, days after his fourth birthday, her son died of an internal infection, and then her marriage fell apart.

Anguished and aggrieved that she’d lost what she considered the epitome of female hood, a husband and children, Breckinridge made a bold move: she renounced motherhood, and  in June 1918, at the height of the Spanish Flu, she left her husband and headed to the congested slums of Washington, DC as a public health nurse. For months, she traveled to the homes of stricken were she found them laying in rooms “riddled with bedbugs…[that] dropped down on the patients from the ceiling.”[1].  She killed them by sticking their legs in carbolic acid.

When the epidemic ended, she left for France as a volunteer for the American Committee for Devastated France, an organization founded to help France recover from the ruin of World War I.

The southern belle, who once wore fine silks and attended coronation ceremonies, now spent her days walking through the shattered villages with their bombed-out roads, open trenches, and roadside graves heaped with decomposing soldiers. She brought food and clothing and supplies to the dispossessed civilians; she nursed those maimed by explosives and those sick with tuberculosis and other infectious diseases. In addition, she organized a special program for children and pregnant women and a Child-Hygiene and Visiting-Nurse Association. Her work earned her the Médaille de la Reconnaissance Française,

While there, she encountered midwives and began thinking deeply about healthcare in rural America, particularly for pregnant women and their babies. She noted: “…midwives were not nurses. In America nurses were not midwives. In England trained women were both nurses and midwives…it grew upon me that nurse-midwifery was the logical response to the needs of the young child in rural America”[2].

In 1922, Mary returned to the United States with a progressive vision of bringing maternal-fetal medicine and healthcare to remote places. After studying public health at Teachers College at Columbia University, she chose to survey one of America’s most remote and poverty-stricken regions: Leslie County, in the Eastern Kentucky Appalachian Mountains, which included over 700 square miles of territory where the elevation ranged from 757 – 2600 feet above sea level.

Alone, on horseback, she rode winding trails for hours, arriving at isolated mountain cabins. The “mountain people,” as they were called, welcomed Mary, inviting her to stay overnight and eat meals of pork and cornbread. Over long dinners, they told her about life in this faraway place. She learned from rawboned men how they struggled to feed their families; in summer, they raised livestock and harvested corn from unruly soil; the winters, brought icy winds that froze their faces as they cut timber to store until spring when the rains came and thawed the rivers. Then, one by one, on the fresh currents, they would send the logs downstream. This was often the only cash they earned.

The women talked openly about the lack of healthcare and access to doctors; they confided in her about the “midwives,” local women who were delivering babies. There were 17, all untrained, and when complications arose, they reached for magic or folk lore or tradition religion. Some repeated Bible verses, other used herbs; a few stuck axes or knives under the bed to “cut” the pain. But women still died, adding to a growing statistic sweeping the rural America—for every 100,000 live births, over 800 resulted in maternal death [3].

Mary was horrified, and her later writings reveal that she viewed these pseudo-midwives not as women desperate to help, but rather as “filthy” and their practices as “medieval.”  Her revolution at the state of affairs in rural Kentucky solidified her mission to establish a nursing service and provide proper healthcare, nursing and midwifery, to the people in this far-flung place. But, one can’t help question the deeper motives of such progressive reforms: Did Mary really care about the people of rural Kentucky or did she want to “reform” them based on her own conservative views of motherhood?

In 1925, in Hyden, KY, she opened the Frontier Nursing Service (FNS), becoming the first organization in the country to employ nurse-midwives, women who would deliver babies and also tend to the sick. Later that year, she moved the headquarters to her home, a log cabin she called the “Big House,” in Wendover, KY, which also served as a clinic.

But, more was needed. FNS charged $1.00 for a year’s coverage and $5.00 for childbirth. If a family couldn’t pay, they could barter; if that was impossible, they worked for free. No one was ever turned away.[4]. To gain public support and raise money, Mary began a public relations campaign.

Together with her niece, Mary “Marvin” Breckinridge, a cinematography student, they produced a documentary film The Forgotten Frontier that showcased the work of the Frontier Nurses. The film along with her wealthy connections and speaking engagements, eventually helped to raise millions of dollars, enabling her to open outposts and eventually the Hyden Hosptial, the first hospital to grace the area.

There was more: in 1939, she opened the Frontier Graduate School of Midwifery to educate nurse-midwives who would work in rural and under-served communities across the country. The school, still in operation today in Kentucky, evolved into the Frontier Nursing University.

To many, Mary was the “heroine of the highlands,” and an “angel on horseback”; while her accomplishments, especially during her time, are notable, she wasn’t an angel, she was a mortal, and mortals are inherently flawed. In recent years, new scholarship has emerged on Breckinridge, highlighting her nuanced, and at times, antiquated, stance on issues of gender, contraception, and race.

For forty years, she advocated for the “mountain” women of Eastern Kentucky to have access to maternal-child health, but her support came from a traditional ideology of women being happier as wives and mothers who produce “citizens and soldiers for the nation.” Her conviction was upheld by her personally controlling “the availability of contraceptive devices and information to her patients.” Whether the women knew Mary was withholding contraception, is unclear. And would it have mattered? To them, she was a friend, someone trying to help. But, her writings reveal the feeling wasn’t mutual. Often, she spoke about their naiveté and lack of intellect and her need to speak in simple language.

When it came to race, here too, Mary didn’t mince her words: Stemming from  her aristocratic antebellum southern ideology passed on from her family, Mary saw blacks as second-class citizens, who would always be subservient to whites. A staunch proponent for racial segregation, Breckinridge refused to hire black nurse-midwives, or to have a black person sit at her table.

While we can (and should) celebrate her achievements, we cannot ignore emerging scholarship that casts her in a radically different light. Hopefully, in the future, the angelic image of her will begin to dissipate, giving way to a more authentic picture of her as a multifaceted woman, who often held disparaging (and racists) beliefs about the people she so desperately wanted to help.


*All photos by Marvin Breckinridge





Works Cited:


[2] Breckinridge, Mary. Wide neighborhoods, a story of the frontier nursing service. Lexington: The University Press of Kentucky, 1952, page 111.

[3] Centers for Disease Control. (1999). Achievements in public health, 1900-1999: healthier mothers and babies. Morbidity and Mortality Weekly Report, 48 (38); 849-858





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