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There’s a reckoning at the end of every war. Counting the cost of American dead after World War One caused a few to reflect on a much more disturbing statistic: far more American women had died in childbirth than American men in war, including the Civil War which elevated martial slaughter to an industrial scale.

Thousands of US nurses had served in Europe where they learned the value of well- trained midwives. Returning home, they were left to ponder why the world’s richest power had among the highest maternal death rates of any country – four or more times that of some places in Europe.

The reasons were complex: it wasn’t a political or social priority, unqualified “granny” midwives still prevailed, medical authorities were dismissive if not contemptuous; and many women simply did not have access to any care.

It made a mockery of all the notions of motherhood and apple pie idealised in Alonso Foringer’s portrait which was adopted by the American Red Cross.

New York City provided the focus of those pressing for change. And prominent among them was Mary Breckinridge.

She had been born into a rich and influential Southern family. Her grandfather was the only presidential candidate to later face the other contender in battle – in 1864 as a Confederate general in a raiding force looking over at Abraham Lincoln in Washington.

Breckinridge suffered the tragedy of losing both her children before they reached the age of five. Trained as a nurse, she worked for the American Committee for Devastated France before qualifying as a midwife at Woolwich in London.

Her ambition was to establish an effective nursing and midwifery service in rural Kentucky. The model she chose – or maybe it chose her – was the Highland and Island Medical Service in Scotland (HIMS).

HIMS was established in response to recommendations from the Dewar Committee. It took evidence for four months and managed to pull together its final report in just one day at the North British Hotel just before Christmas 1912. Smart work for what, arguably, was the most important Scottish health legislation of the 20th century.

HIMS was a unique social experiment predating the NHS by 35 years. Medical and nursing services were either poor or non-existent in many areas within the crofting counties, which were not effectively covered by the national insurance scheme for workers in the rest of Britain.

It was established in 1913 with an annual Treasury grant of £42,000 to the Scottish Office which distributed it to local nursing and other organisations.

Fees were set at minimal levels but inability to pay did not prevent people from getting treatment. State resources were directed to basic needs – providing a house, telephone, car or motor boat to get around and cover for further study and holidays.

It had obvious appeal for Breckinridge. She made contact with Sir Leslie Mackenzie who had sat on the Dewar Committee and was medical member of the Board of Health – in effect Scotland’s chief medical officer.

Sir Leslie and his wife Helen had also been close friends of Elsie Inglis. She ran a small hospital in Edinburgh’s High Street for women and children prior to setting up the Scottish Women’s Hospital Service (SWHS) in World War One. It is no coincidence that the remaining funds of the SWHS when it was wound up were devoted to setting up maternity hospitals in Edinburgh and Belgrade.

Armed with a letter of introduction from Sir Leslie, Mary ventured forth. It was a journey that was to change her life.

“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 to make a study of the Highlands and Islands Medical and Nursing Service, 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.

Tellingly, Breckinridge added “and Nursing” to the Highlands and Islands Medical Service title. And she was right – nursing was what the Dewar Committee had identified as the most urgent need.

Mary’s first port of call was the Scottish Headquarters of Queen Victoria’s Institute for Nurses. Highly-trained “Queen’s Nurses” provided the backbone of the HIMS. Many had additional qualifications in midwifery (regulated as a profession in England from 1902 and in Scotland from 1915).

She then went off to meet them. A letter of introduction from Sir Leslie opened doors across the Highlands and Islands. It proved an epiphany – she was overwhelmed by the warmth and kindness of the welcome from the communities and midwives, particularly in the Hebridean islands.

Breckinridge also took copious notes – 11,000 words of her meetings and experiences. Her meticulous approach extended to several studies of the population in Kentucky. This was pioneering epidemiology – long before the time made it into medical textbooks.

She developed the concept of the nurse midwife – providing not just care around births but also public health nursing looking after entire families. It was revolutionary – and a sound statistical base was essential to demonstrate that it worked.

As in parts of the Highlands, births and deaths had gone unrecorded for years. To demonstrate what nurse midwives could do, they would need evidence and what followed was a classic early example of nursing-led epidemiology.

Breckinridge contacted Sir Leslie and tracked down Miss Williamina Bertram Ireland, (what makes you think her parents wanted a boy?) who had acted as secretary to his inquiry on the Physical Welfare of Scottish Mothers and Children and later had done field work in the Western Isles for his report on housing for the Carnegie Trust.

She had served with the London unit of the SWHS in Salonika and moved to the US after the war to work for the Committee on Maternal Health in New York.

Miss Ireland had two further essential qualities. She could ride a horse and she could take a nickname. The Frontier Nursing Service also pioneered the now blokeish practice of giving nicknames to each new member of staff. “Ireland from Scotland” became the first of many.

Ireland passed the first test – the 20 mile ride from the railheads Krypton or Hazard around 20 miles across mountains and fording rivers and streams.

In June 1925, Breckinridge noted: “She has begun her work on Hell-fer-Startin’ Creek and Devil’s Jump Branch – really. She is blistered, sore, stiff, and undaunted”

She had chosen Leslie County in the eastern Appalachian Mountains – the name is a bit of a giveaway recalling the Scottish immigrants who first settled in Kentucky.

An early landmark was building the first FNS hospital – at Thousandsticks Mountain in Hyden. There was only one choice to perform the opening ceremony on June 26 1928. Sir Leslie Mackenzie, then 66, and Lady Helen were delighted to oblige. Neither could ride so a buckboard was brought in for the 22 mile journey from the railroad involved teetering over precipices in a violent rain storm and fording the swollen Kentucky River.

He waxed lyrical in his address, later published in the Lancet:

“It is a story full of adventure, sacrifice, passionate enthusiasm and splendid initiative. When, some years ago, Mrs Mary Breckinridge came to us in Scotland to see how we had faced a similar problem in medical service and nursing, we were filled with a new sense of significance of the work we had tried to do in the thinly peopled and difficult areas of Scotland.

“When, therefore, I was invited by the Frontier Nursing Service of Kentucky to give verbal form to the dedication of the hospital and nursing system now established in these mountains, I felt indeed, a glow of supreme satisfaction that our work in Scotland had found an echo in the great spaces and mountains of an American Commonwealth. 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…..

“The beacon lighted here today will find an answering flame wherever the human hearts are touched with the same divine pity. Far in the future, men and women, generation after generation, will arise to bless the name of the Frontier Nursing Service.”

If you’ve read this far, you may be ready for a musical interlude. Kentucky and the Celtic nations already had links forged by migration, music and moonshine before the arrival of midwives.

Listen here to Jean Ritchie, the queen of American folk music, who would have been six years old when Sir Leslie was making his speech. She was born and raised in Viper, a few miles from Hyden. This recording on the Tobar an Dulchais site dates from her Fulbright year in Scotland in 1953.

The Frontier Nursing Service may have a good claim to the first Healthcare Maintenance Organisation in the USA – it certainly predates Blue Cross, Blue Shield and Kaiser Permanente.

Whatever skepticism it faced at the outside, an external audit provided astonishing vindication of the work of the FNS:

“We have had a small but convincing demonstration by the Frontier Nursing Service of Kentucky of what the well-trained midwife can do in America. …. The midwives travel from case to case on horseback through the isolated mountainous regions of the State. There is a hospital at a central point, with a well-trained obstetrician in charge, and the very complicated cases are transferred to it for delivery.

“This study shows conclusively that has in fact been demonstrated before, that the type of service rendered by the Frontier Nurses safeguards the life of the 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 a 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.”

You might pick him up for his grammar (should have been ‘fewer’ rather than ‘ less’) but no-one could doubt his authority. The audit was carried out by Louis I Dublin, vice president of the Metropolitan Life Assurance Company in New York and former president of the American Public Health Association, the foremost health statistician in the United States.

The first five years had brought astonishing success for the Frontier women but the next decade was to prove far more testing….. read part two here

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Categories: case studies, digital history, history on the web, medical and nursing