- Mary Breckinridge: The Frontier Nursing Service and Rural Health in Appalachia
The broad outlines of Mary Breckinridge's life and her innovative Frontier Nursing Service (FNS), which brought the idea of nurse-midwifery to the United States, are generally known. Breckinridge was born into a family of wealth. Widowed at a young age, she moved out of the southern mold of domesticity and selected nursing as an appropriately self-sacrificing career. She graduated in 1910, but soon after that, her desire for motherhood led her to remarry. The death of her beloved son, Breckie, in 1918 inspired her volunteer efforts in the areas of maternal and child health. Similarly, postwar conditions in Europe impelled her involvement in the American Committee for Devastated France, and, during her months in France, she honed administrative and fund-raising skills.
Breckinridge returned to the United States determined to bring modern health care to the residents of Appalachia. She had two reasons for choosing Leslie County, Kentucky, for her venture. First, the family name of Breckinridge gave her immediate recognition and status in the area, important elements in gaining acceptance for her program and in attracting funding. Second, she intended Leslie County to be a demonstration: if she could lower the mortality and morbidity statistics here under the most difficult conditions—poverty, isolation, and lack of professional health care practitioners—then her plan promised to succeed anywhere. The heart of the FNS was its nurse-midwives. These women, many of whom were from Britain, faced the arduous tasks and unexpected dangers of rural life in Appalachia, which typically lacked running water or power and which could be accessed only on horseback. Goan details how, through the force of her personality and commitment, Breckinridge inspired nurses, donors, and staff to devote their expertise and energies to the FNS.
After World War II, the situation was significantly different. Breckinridge was older, and her health was slowly failing; the modern world had altered Leslie County with the introduction of roads, television, and the like. Through the 1940s and 1950s, Breckinridge resisted changes to the FNS and turned to cementing her legacy, most specifically through attacking journalists whom she felt produced an inaccurate picture of her or of the FNS and by writing her autobiography, Wide [End Page 148] Neighborhoods (1952). The book was a strategic public relations tool, and its royalties provided crucial funding for the FNS, which, until the advent of Medicare and Medicaid in the 1960s, did not accept government funding.
Goan takes us behind the simple story of the FNS to understand the factors that drove Breckinridge to design and fight for this striking health care delivery system. She skillfully analyzes how Breckinridge constructed the mythology around the FNS. Breckinridge was the consummate publicist, creating a persona that attracted the attention she needed, financial and otherwise, to maintain the organization. Goan is best in pointing out the complexities and contradictions evident in Breckinridge's work, such as the way her class and racial biases played out at the same time as she attempted to improve conditions in Leslie County. Clearly impressed with the founder of the FNS, Goan often points out how other historians have slighted Breckinridge's intentions. Yet, Goan reaches beyond her sources in striving to explain Breckinridge's motivations. To give one example, in the 1950s, there was an increasing demand for hospitalized childbirth. Goan claims that despite the community's needs, Breckinridge resisted expanding her hospital, and that this "reflect[ed] her desire to maintain her organization's distinctiveness [as a frontier service]" (p. 234). That is possible, but there is nothing to substantiate the author's claim. Undocumented assertions such as these mar an otherwise interesting biography of a health care visionary.