Midwives on horseback: Saddlebags and science
In 1931, the documentary The Forgotten Frontier asked, "Do you know that America is still a frontier country for about fifteen million people, with almost no medical, nursing or dental care? And that in our history, we have lost more women in childbirth than men in war?" Fortunately, there was a solution to these problems—at least for poor women and families in eastern Kentucky—and that solution was the Frontier Nursing Service (FNS) and its nurse-midwives on horseback.
Mary Breckinridge, a public health nurse and midwife from a distinguished Southern family, had founded FNS in Kentucky's Appalachian Mountains in 1925. In that year, as The Forgotten Frontier put it, "a new kind of 'fotched-on' woman [an eastern Kentucky phrase meaning women fetched from other places to to work with the mountain people] first appeared in the wild Kentucky highlands." This "'fotched-on' woman" was a professional nurse-midwife (a registered nurse with training in midwifery).
Marvin Breckinridge Patterson, Mary’s cousin, directed the silent film, “The Forgotten Frontier,” in 1931. Watch on YouTube.
"In the saddle all weathers," the silent film explained, the nurse-midwife "found her way to isolated mountain cabins, making friends with bright-eyed children, tending women in childbirth, spreading ideas of 'furrin' [foreign] sanitation and hygiene." Serving families in a 700-mile area extending into four southeastern Kentucky counties, FNS had, by 1930, six outpost centers, with two nurse-midwives at each responsible for both the general health of all of the families as well as prenatal, labor and delivery, and postnatal care for women in their district.
The narrow winding roads of Appalachia meant that nurse-midwives might have to ride for up to an hour on horseback to help a woman in labor. Though supervised by physicians, the isolated nature of rural Kentucky meant that these midwives often worked independently, carrying supplies with them.
When Breckinridge did a horseback survey of 53 local midwives in 1923, she found that local "granny" midwives (a term used to refer to Southern lay midwives until at least the mid-20th century) provided inadequate and outdated care to their mountain patients. Few of these midwives had formal midwifery training, and few used modern equipment. This survey helped Breckinridge demonstrate that Kentucky women and their families needed care from a new kind of birth attendant—a nurse-midwife who would provide modern, professional care and who carried scientific and modern equipment in her saddlebags.
The nurse-midwife carried all of these materials in her saddlebags because she was usually far from both her outpost center and the small FNS hospital; she had to be prepared for whatever she found. With the help of the equipment in those saddlebags, FNS nurse-midwives lost astoundingly few mothers. FNS was a great success by any measure.
These saddlebags were essential not only to the health care and midwifery work of nurse-midwives, but also to the public relations campaign that Mary Breckinridge cleverly conducted to gain financial and general support for FNS. At a time when urban, middle-class women were giving birth in hospitals with physicians, Breckinridge began a service for women giving birth at home with nurse-midwives. Photographs of babies in saddlebags and nurse-midwives on horseback helped build public support for this seeming anomaly in professional health care. Ultimately, FNS got tremendous support from the wealthy and the prominent in great part because it was serving people who were literally off the beaten path and who would not have had access to physicians anyway.
Kentucky, the birthplace of American nurse-midwifery, now houses Frontier Nursing University, which has provided graduate education to nurse-midwives (and more recently, nurse practitioners) since 1939. This university combines distance education and clinical work in the student’s own community to educate a significant percentage of American nurse-midwives.
Today in the United States, there are 39 accredited graduate midwifery education programs and over 11,000 certified nurse-midwives and certified midwives (a newer kind of professional birth attendant). In 2012, the most recent year for which we have statistics, those professional midwives attended 11.8% of all vaginal births and 7.9% of total births in the United States. They attend the births of women of all income levels, races, and ethnicities in urban, suburban, and rural areas and serve as primary care providers for women of all ages.
Guest blogger Laura Ettinger, PhD, is an associate professor of history at Clarkson University and the author of Nurse-Midwifery: The Birth of a New American Profession.