MARY: I had the honor of starting the Frontier Nursing Service with the wonderful cooperation of a host of friends and kinsmen.

Seven generations of my family are buried in Kentucky soil and among these are the bodies of my own two young children.

I couldn'’t possibly have founded anything or even started anything without the immense help and cooperation of my fellow Kentuckians.

I had generations of friendship behind me and among those generations were many mountain friends.

I spent a whole summer once riding over the mountains, sleeping wherever night overtook me.

And everybody was glad to see me, and everyone felt that something that would conserve the lives of young children and their mothers needed to be done!

♪ ♪♪ NARRATOR: In 1925, nurse-midwives from across the globe began traveling to Leslie County, Kentucky to demonstrate the possibilities of rural healthcare in America.

Led by Mary Breckinridge, these spirited women delivered unprecedented care to the families living in remote regions of Appalachia.

Their efforts reduced the maternal and infant mortality rates to be among the lowest in the nation and improved the overall welfare of these mountain communities for generations to come.

SUSAN: Mary Breckinridge was the founder of Frontier Nursing Service.

Of course, that happened about half- way through her life.

She came here to start the service when she was 44 years old, so there's a lot of history before that time.

NARRATOR: Mary Carson Breckinridge was born in 1881 into an American political dynasty.

Her great-great grandfather first settled the Breckinridge family in Kentucky in 1793, and later served as Attorney General to Thomas Jefferson.

Her grandfather was John Cabell Breckinridge who served as Vice President under Buchanan and fought for the Confederacy, rising to become a general and the last Secretary of War under Jefferson Davis.

MELANIE: She was definitely a product of the old South and had grown up hearing stories of the glories of bygone days before the war came and destroyed the old South.

NARRATOR: In keeping with the ideals of the Antebellum South, her parents raised their children to accept the existing racial order, including segregation.

Conversely, the Breckinridge legacy instilled the noble values of integrity, honesty, and self-sacrifice.

Applying those principles, Mary discovered her passion for healthcare at a young age.

MARY: In looking back over the years of my childhood to find things that had a bearing on what came to be the Frontier Nursing Service, there is one event that stands out in my memory above all others, and that is the birth of my younger brother in Russia in the early '90s.

My father was the American Minister in Cleveland's second administration, and we were living in what was then St. Petersburg.

We had not had a baby in the family for 10 years.

I was 14 years old.

SUSAN: You know she tells about it as she remembers the midwife was in charge of the situation, although there were physicians there as well just in case something went wrong, and they weren't really needed because it was a nice, normal birth.

So that stuck with her.

MELANIE: And growing up in the South, as a young woman, you were told that you were to be a wife and mother, hopefully to some wealthy, powerful, influential man, that would be the goal to marry well.

But, then you would support your husband's career.

And her parents, certainly that was their priority.

That's what her mother had modeled.

But there was something in Mary too, I think that was really, she was dutiful, she knew what was expected of her and she planned to fulfill that.

NARRATOR: She married Henry Ruffner Morrison in 1904, but the union would not last more than a year.

He succumbed to a ruptured appendix while escorting his young wife home from New York where she had been seeking medical care to address their trouble in conceiving a child.

His untimely death would change the trajectory of her life.

SUSAN: And at that time, she right away decided that she wanted to do something different and do something for humanity.

That was an interesting time because her family, they were not that interested in her getting an education.

She wanted to get an education.

She wanted to serve, even as a younger person.

But when she was older, she just took the reins herself and said, "I'm gonna go be a nurse," and so she did.

NARRATOR: Mary completed the rigorous training at St. Luke's Hospital School of Nursing in New York City, graduating and passing the state boards with honors in 1910.

But, instead of immediately entering a nursing career, she answered her parents' call to return to them in Arkansas.

A year later she met her second husband, Richard Ryan Thompson, president of the Crescent College and Conservatory in Eureka Springs.

Mary applied her education and prowess for storytelling by teaching courses in French and hygiene at the school and writing a series of articles for Southern Woman's Magazine, and she fulfilled her dream of becoming a mother.

On January 12, 1914, Mary gave birth to a son, Clifton Breckinridge Thompson, lovingly called Breckie.

MARY: My part in the story of the Frontier Nursing Service cannot be told without telling the story of Breckie.

MELANIE: Breckie was certainly one of this Earth's most adored children.

She fixated on every detail of his development.

She would measure his food, she weighed him daily, every detail mattered to her.

But at the same time, she has this profession, and she is a working mom.

Her son is sitting in her lap a lot of the time while she's working and it's wonderful to find his scribbles in the margins.

And the things she's writing at the time have to do with how to be a good mother.

So, she's instructing young girls through the college about scientific mothering, not just any kind of mothering but how to do it the right way.

NARRATOR: While rooted in nursing and healthcare, her writings were also shaped by the study of eugenics, a controversial scientific theory that grew to prominence at the turn of the century.

ELLEN: It was based on the idea that through breeding you could improve the human race and that the better specimens should reproduce at a greater rate than the inferior specimens.

So the movement was well accepted by many, many educated people.

MELANIE: I mean these are leading figures.

This is not a fringe movement or anything like that.

Well Mary Breckinridge, she certainly sees herself as the right person to have a baby and then she's encouraging other white middle-class women to do their duty.

NARRATOR: Her approach to motherhood could not prevent complications during her second pregnancy and on July 8, 1916, her daughter, Polly, was born prematurely and lived only six hours.

In coping with her grief, Mary became even more devoted to her son.

MELANIE: Breckie, her son, was her hope.

And that was her hope for the future.

She almost lives vicariously through him, he's gonna go and do all the things that she as a woman with the limitations of her sphere, she can't do those things herself, but she can raise a young man who can go and save the world from poverty and all the problems that threaten children especially.

MARY: On January 12, 1918, came Breckie's fourth birthday.

On the 23rd of January Breckie died.

Of his swift illness and death, I cannot write except to say that he played his part of brave soldier while conscious life remained in him.

He had taken all the unaccustomed suffering terminating his happy life, without questioning why it had come, because he believed it was right for a soldier to be brave.

MELANIE: He was a well-cared for child, he had a nurse as a mother, he came from a family of means, he had every advantage that a child growing up in the nineteen- teens could have, and he still died because death stalked families and they stalked even families like Mary Breckinridge's.

SUSAN: This was devastating for her, as it would be for anybody, but for Mary Breckinridge it was a big part of her identity to be a mother.

She wrote a whole book about Breckie and his four years on this Earth.

And she decided at that time she really needed to do something bigger than what she was doing, and she wanted to do something to serve children.

She really thought if there was better healthcare, her children may not have died.

MELANIE: She throws herself into work to also cope with her grief.

And so right after Breckie's death, I think it's twelve days later, she's already corresponded with some of her nurse colleagues in the American Red Cross and she has been granted a commission to go overseas, this is of course during World War I, there's a need for nurses, and as soon as Breckie dies she says, "I'm available, send me to Europe, I'll go and work there."

And so, twelve days later they're telling her, "Yeah, we'll take you, we'd love to have someone with your skills."

She spoke several languages, she was a nurse.

She could be useful, and so they were ready to accept her.

NARRATOR: Being of service overseas presented a distraction from her grief and an escape from a deteriorating marriage.

ELLEN: That northeast part of France was the site of German occupation and of several offenses that literally destroyed the earth itself, so it was truly devastated.

There were aid organizations of all kinds flocking there as soon as the fighting stopped.

NARRATOR: One group was run by the youngest daughter of wealthy banker J.P. Morgan.

Anne Tracy Morgan was a celebrated philanthropist who needed nurses and administrators for her relief organization.

BEATRICE: It was a very strong organization, the American Committee for Devastated France, Comité Américain pour les Régions Dévastées, and we all wore uniforms, we wore French blue uniforms.

So everybody in the area knew who we were.

MELANIE: She'd always wanted adventure even though she'd done her duty and done what her parents asked and took the traditional route, there was always part of her who craved adventure.

She liked to hunt as a child and she liked to explore and now suddenly here she is in France and she is bumping across the countryside in an ambulance, driving it herself.

And she is seeing new places and war torn areas and it's heartbreaking, but I think it's really thrilling for her too, to have that adventure, and she learns a lot in the process.

NARRATOR: A year into her service, a brief leave of absence to Fort Smith, Arkansas made possible a swift divorce for Mary Thompson, effectively ending a difficult chapter and enabling her to begin anew.

BEATRICE: This particular day I remember, Mrs. Breckinridge saying, "I am no longer Mrs. Thompson.

I'm divorced and I'm now Mrs. Mary Breckinridge."

(LAUGHING) MELANIE: Probably she didn't elaborate any more than that I'm guessing, but "Call me Mrs. Breckinridge," which is not her real name, she was never Mrs. Breckinridge.

She would have been Miss Breckinridge, but Mrs. gave her some legitimacy.

NARRATOR: Mrs. Mary Carson Breckinridge slid back into her familial surname with the intent to uphold its legacy.

It is a Breckinridge's duty to serve and excel and she would maintain that obligation through her life's work, employing her moniker to influence her peers to support her causes.

BETTY: She always used to tell us a little story that they needed milk, very badly.

She wrote to all of her friends and said that she either wanted the money to pay for a goat or she wanted a goat.

Well, she was the one who went all around everywhere supervising everything, and when she got back to headquarters one day, she found 29 goats waiting for her so, the children had enough milk from then on.

MELANIE: And she realizes, "Hey!

"I have this network of people that if I ask, "they're going to respond, they're going to care about these issues."

And so that, having the fundraising piece is going to be important later on, and the idea of district nursing too, where you can have medical professionals that are kind of spaced around a rural area that can care for a large population of people in a very efficient way.

That she learns in France too.

ELLEN: She met a group of confident, hearty women and obviously she was going to draw on that idea that you could actually gather a band of women, of genteel birth generally.

SUSAN: She also noticed that the nurse-midwives were both public health nurses and midwives, and she realized very quickly that this was a model that could improve health.

MARY: It grew upon me that nurse-midwifery was the logical response to the needs of the young child in rural America.

In America, much had been done for city children, whereas remotely rural children had been neglected.

My work would be for them.

In 1923, with a whole summer free to spend as I liked, I spent it in the Kentucky mountains.

As to hospitality, I cannot even remember the names of all the people whose houses I have ridden at nightfall, nor were my horse and I ever turned away.

BETTY: When she was here, Mrs. Breckinridge saw that the people were self-supporting, they practically all had their little farm, they had their cow and their hogs and their chickens, and their garden.

And they were very proud, they wouldn't accept charity at all.

But they were very proud, very self-sufficient except they had no medical care and she saw that that's where she could help.

MELANIE: Once she decides that she's gonna create a nurse-midwifery organization, she has to be a nurse-midwife and she had the nursing training.

So, she goes for several months to Britain and enrolls to become a certified midwife.

BETTY: She went to London, she took her midwifery training at the British Hospital for Mothers and Babies, then she went up to Scotland and there she met Sir Leslie MacKenzie in Edinburgh and he was the head of the Scots nurses and he suggested that she should go up to the Highlands and the Islands of the Hebrides and see what the nurses were doing up there.

SUSAN: She went to Scotland and she spent about 10 months over there, touring midwifery services and public health nursing services.

Scotland had the same nurse-midwife model, and she got a lot of her ideas for Frontier Nursing Service from her time in Scotland.

And she made a lot of good friends there, too.

MARY: Early in 1925 I came back to Kentucky.

The years spent getting ready to work for children had ended.

It was time to begin.

MELANIE: Kentucky made sense because her family roots were so deep.

The Breckinridge name was gonna open doors for her.

And she believed eastern Kentucky of all places where she could demonstrate her project.

She needed the place that was most remote, where the conditions were most difficult to start out.

Because if she could succeed there, she could succeed anywhere, and the model could be replicated.

NARRATOR: Building in eastern Kentucky would be grueling work, but it also had an advantage.

The seemingly simple way of life often piqued the interest of Americans tired of toiling away in the cities and Breckinridge could capitalize on the attention.

MELANIE: Certainly, Appalachia was having a moment and we've held this region up as sort of an anomaly, but in some ways it represents sort of the heart of America in a way that people have attached a lot of significance to the mountains.

This is people that are living like our ancestors did and Americans are a little nostalgic for a past that seems to be quickly disappearing as America industrializes and urbanizes.

And so, we can come in, we can offer good medical assistance and we can give these people a leg up so they can really contribute to the America we imagine and in keeping with her views on eugenics to offer this area up as the solution.

NARRATOR: However misguided those views were, Breckinridge utilized this narrative to appeal to wealthy peers with similar sentiments.

Ultimately though, she sought a solution to the inaccessibility of healthcare in rural areas nationwide.

The United States' medical system was in its infancy, and she had hoped to help mold it to meet the entire country's needs.

But institutional biases proved difficult to navigate when it was time to introduce her new healthcare model.

ELLEN: In the U.S. there was a lot of hostility to the idea that midwives should be trained as nurses, because it denigrated their skill.

JOYCELYN: The obstetrician gynecologists felt that the nurse-midwives couldn't provide the kind of care and all that they were really trained to provide.

MELANIE: She had tried to get funding from a national organization, foundation support.

And she'd always thought that the Federal Government would pick this up, once she could show how well it worked.

So, she pitches the idea to several foundations.

And all of these come back and they're not going to support this organization.

And then she starts to pull together the people she's going to need to back the project across the state of Kentucky.

NARRATOR: The Kentucky Committee for Mothers and Babies held its first meeting in May of 1925 at the Capitol Hotel in Frankfort.

The board was comprised of Breckinridge's well connected friends and relations whom she had convinced of the importance of establishing professional midwifery in America.

SUSAN: And people became very excited about the project, and they all just said "Yes, this is a good idea, and we will support this project."

Although they did not offer financial support.

But it was enough for her to say, "All right, "I tried to get grant funding, "I've tried to get other funding, "I'm just gonna use all the money that I have, and start this service."

NARRATOR: Mrs. Breckinridge utilized a small inheritance from her mother's side of the family to kickstart the budget.

Dr. Arthur T. McCormack, the health commissioner for the commonwealth, recognized the benefits the service could bring to the rural communities in Kentucky and his first recommendation was to capture baseline data of birth and death rates so their work and impact could be measured.

A survey of the area was the inaugural task for the newly hired nurses.

EDNA: We took turns, we went in different directions, and we made a survey to find out.

We wanted to know the way around, we wanted to get acquainted with the people and tell them what we hoped to do.

ELLEN: The United States around in the early 1900s was number 17 out of 20 comparatively wealthy nations in terms of infant mortality and maternal welfare.

The U.S. figure for maternal deaths was 6.7 per thousand.

Now that sounds like not much, it's under 1%, but if you assume that a woman can have 10, 12 childbirths and each time she's reckoning with a statistic like that.

And it was considered a very bad statistic.

MELANIE: In 1900, 50% of women gave birth at home with a midwife.

By 1930, only 15% of women are attended by a midwife.

In early 20th century, there's this backlash against midwives, painting them as a threat to society, and that if you have the means you need to have a trained physician, you have to have the best of the best there ready to handle any situation that arises, and a midwife isn't prepared to do that.

Ignoring the fact that midwives had delivered babies for hundreds of years!

NARRATOR: Gaining support from local and regional doctors was vital to the nurses' endeavors in the mountains and though they were highly capable, they had to be cautious not to overstep the doctors' authority.

Medical routines were created by doctors for the nurse-midwives to use in the field.

SUSAN: We have, I think, 26 volumes of the medical routines.

And these documented how to manage snakebites, gunshot wounds, diarrhea, worms, whatever the case may be, there was a lot of documentation that went into how to provide this care.

NARRATOR: Care was provided from a small, rented home in downtown Hyden that served as the temporary headquarters while Breckinridge's permanent home was built a few miles away in a location she had chanced upon during her summer visit in 1923.

MARY: It was on one of my rides alone that I first saw Wendover.

Of course, it wasn't Wendover then, but I knew it would be.

To myself and to my horse I said, "Someday I'm going to build me a log house right there."

Two years later I did.

CARLYLE: Mary Breckinridge built this beautiful log cabin called the Big House and it's above, up on a hill looking down towards the Kentucky River and across the river she bought the property on the other side so she would always have a good view.

And she had it built to her specifications.

SUSAN: She wanted this to be a demonstration project, so she wanted to be able to host people from everywhere they could come and see how this project worked and what the results were.

NARRATOR: Wendover's completion was celebrated with a Christmas gathering of 500 neighbors at the Big House.

The home and hearth were dedicated to the memory of her children SUSAN: When the Big House first opened, she really wanted it to be an open place where people could come.

And she actually started a post office here, so that was one way to get people to come and get to know people.

She also used this as a cottage hospital.

Some people would describe it as almost a self- sustaining farm, because they did grow their own pigs, their chickens, some vegetables and things like that, and she did like to tend to those things.

CARLYLE: She was very against material things, and when she had the Big House built, the one extravagance she allowed herself was to have a bathtub put in the bathroom.

But, aside from that she lived a very kind of spartan life.

NARRATOR: Although establishing her homestead in the hills would help bridge a connection to the community, the social and cultural divide was difficult to surmount.

MELANIE: Behind the scenes when you read through the correspondence, you can see that the nurses are really having a hard time winning patients' trust.

BETTY: Now when they came in, of course everybody wondered what these queer women were doing here, what were they up here for, what did they want?

Well, Mrs. Breckinridge came in and she said, "Now we're here, we're nurses, and we're midwives.

"You come and visit us "and we'd like to visit you, "but we are not coming into your homes unless you invite us."

Some people come in and they say, this that and the next thing, we're do-gooders, they're gonna do this that and next and change everybody's life.

But she didn't do it that way at all.

SUSAN: So she wanted to know from the people themselves what did they want to see from the service?

What were their ideas, what were their needs?

She knew she had to take care of their needs first before she could start introducing some other public health ideas.

MARY: But she was working together with the people and not just for them.

NARRATOR: Collaboration with the community was a cornerstone of the organization and resulted in the need for more trained nurse-midwives to meet the growing demand for services.

Nurses who were certified as midwives were not a plentiful American commodity, so Breckinridge's nurses had to be trained and enlisted from abroad.

MELANIE: They recruit British women, women from New Zealand, Scotland, and these nurses are the ones that are coming across the globe to go to Leslie County, Kentucky and offer medical care.

BETTY: Mrs. Breckinridge sent one of her nurses to York Road, the general lying in hospital where I was doing my midwifery training.

And we all got most excited because this American nurse had this album with all these pictures of horses and dogs and creeks and everything and it sounded such a fascinating life to me!

So, I said to her one day, "Do you want any more nurses?"

And she said, "Yes" so I said "I'd love to come."

And they called me into the office and said, "Do you think you're going to Kentucky?"

and I said "Yes, please, I want to go."

"Well, do you know what you're doing?"

They said, "Here you've got the day sister on day duty, you've got night sister on night duty, you've got your doctor within five minutes.

Out there you have nobody!"

Well, I hadn't thought about that, all I'd thought about was having a horse and a dog!

NARRATOR: Nurse-midwives who ventured to serve in the mountains of Kentucky found the terrain treacherous to navigate, but for many, working for Mrs. Breckinridge proved just as challenging.

CARLYLE: She was a very determined, strong-willed women.

And that's one reason she was able to accomplish all that she could.

EDNA: Well she was so straight-laced about things, there was no give to her, there was no give and take.

She used to come up...when we first got there and she insisted that we go out on every call no matter what it was at night and we couldn't take it, we couldn't stand it.

And finally, we just told her, we said "No, Mary Breckinridge we cannot do that, "you've gotta get another nurse in here if you want to do that."

And she said, "If we go out on deliveries, that's all we can handle."

NARRATOR: Within its first two years of operation, the Kentucky Committee for Mothers and Babies had outgrown its name.

MELANIE: As their scope and their purpose expanded, that name didn't match up as well with what they were actually doing and in 1927 Breckinridge changes the name officially to the Frontier Nursing Service, which getting that word "Frontier" in there was useful, because Americans kind of had this notion that Appalachia was still frontier-like, but also spoke to the purpose as being a broader goal that they had to care for not just mothers and babies but fathers, because if children didn't have a breadwinner, they didn't have financial support, they weren't going to grow up to be healthy and successful.

And so, she comes to a more sophisticated understanding of if her organization is going to serve this community what does that look like.

MARY: A young child isn't alone, his first place you've got to conserve his mother before he is born.

The weakest and most defenseless citizens we have are our unborn children and you've got to see him safely through childbirth.

And then what is the use of taking care of him in his early years of life, which are all important to his health, to his emotional life, and to his loving heart.

What is the use of taking care of him then if you let his father die of appendicitis?

You've got to have a hospital and a surgeon within reach where you can take out that appendix if his father has appendicitis.

The child also is part of a neighborhood, you've got to clean up in rural areas, you can't let a young child suffer from harm in his neighborhood.

So, if you take as your focus the young child, you find it leads you into a broad preventive public health program, you'll find it leads you into families, into every kind of situation.

JOYCELYN: She taught them how to work with the whole community.

The importance of painting, the importance of sealing up the houses and windows and the importance of what we call now the social determinants of health.

They educated the women.

And that saved a lot of children and a lot of illnesses, because they knew what to do.

MELANIE: When the Frontier Nursing Service is offering care, they are not just coming in to deliver a baby.

They very much focused on preventative care and offering a level of care that wasn't available even in the cities.

SUSAN: There was one campaign, that they realized that the little girls were getting burned.

And so, they were wearing dresses and petticoats and they would get near the coal stoves, and their petticoats would catch on fire.

Of course, it never happened to the boys who were in overalls.

So, they did a campaign to get the little girls in overalls, and they were able to do that.

NARRATOR: The Frontier Nursing Service was proving its worth, addressing worms, snakebites, infections, and countless other threats to the welfare of its mountain community.

Still, the service remained reliant on donations.

Mrs. Breckinridge traveled the nation utilizing her inherited speaking talents to convince funders to sustain the cause.

She supplemented these efforts by publishing Quarterly Bulletins that were distributed to supporters.

Articles highlighted the nurses' personalities and heroic deeds with harrowing tales of icy trails and swollen rivers woven throughout the organization's needs and medical accomplishments.

MELANIE: I think it's part of what Breckinridge had learned with adopting goats over in France that donors are going to be most enthusiastic when they feel like they are in the scene and involved and so the Quarterly Bulletin does a lot of these vivid scenes.

And she never asked for money, but they would pull out their checkbooks and they'd write those checks because she was able to tell the stories grab them by the heartstrings and pull them in to wanna help.

SUSAN: There's wonderful stories about running across these swinging bridges and the boards are popping up behind them, to get to a woman who's in labor, 'cause you never know if it's urgent or it's not urgent.

So, you're always kind of in a rush to get there.

MARY: On one occasion it was in the winter and it was terribly cold we were riding over the mountain from Red Bird to Hyden.

(DOG BARKING) We were properly dressed for it and had slickers on top and when we got to the hospital at Wendover my hands were so stiff with the cold, I couldn't unbuckle the bridles and so they had to help me.

We went inside and they took off the slickers and they both stood up like people in the middle of the floor, these bright yellow slickers stiff with ice.

MELANIE: Angels on horseback was, that's how Americans came to know this organization and it does become quite well known across the country.

NARRATOR: In 1931, the service lost its first nurse-midwife.

A ruptured appendix took the life of Nancy O'Driscoll, who had answered the call from Ireland.

Her gallant spirit was memorialized in a Quarterly Bulletin.

The harsh reality of the remoteness wasn't lost on any of the Bulletin's readers, or on Wendover's visitors, who often reflected on the region as a step back in time.

SUSAN: The nurse-midwives talked about their motto that "if he can get to me, I will get to her".

And that meant the husbands had to come and get the midwives because there were no phones, there was no other way to do it.

So, if their wife went into labor, they would come here and knock on the door, it didn't matter whether it was snowing, raining, what was happening, they would get up and go out on their horse and they would get there.

MELANIE: These were nurses that were working in rugged conditions, they needed to be outfitted appropriately.

They very much were military inspired and it was inspired from Breckinridge's time in France.

It looked very official but designed for practicality.

If you're going to be riding a horse, you're not riding side-saddle, you're riding astride and so they had to be prepared for weather conditions and the rigors of their work.

BETTY: Our uniforms, she expected us all to be in full uniform and look like FNSers, we were proud of our uniform, and we wore it very proudly.

MELANIE: They were automatically recognizable and seen as professional.

she wanted that to help her patients have a level of respect for these women.

And what they were wearing mattered.

As a nurse you could go anywhere in their territory and men would provide you an escort, very chivalrous men would step forward to protect these vulnerable nurses.

The nurses, they weren't vulnerable, really, I mean they were tough as nails, a lot of them.

NARRATOR: The result of their courage, hard work, and resilience was a working model of a grassroots healthcare system.

SUSAN: She set up kind of the first managed care system in the country right here.

Families would pay a certain amount, I think something like five dollars, to have care for the whole year.

And if there was a pregnancy then it was another five dollars.

There are lots of stories of bartering to pay for that.

While it wasn't always in money, it was in goods or services.

There were lots of maintenance and things to be done.

NARRATOR: The money from the fundraising was used to purchase the materials for outpost centers and the local community supplied the labor.

This cooperative arrangement yielded results and the service sprawled.

SUSAN: Right within the first six years, it's amazing to look at it, because from 1925 to 1931, she built six rural health clinics, and in 1928 built the hospital.

MELANIE: The structure of the Frontier Nursing Service, it was designed to be decentralized and very much patterned off of British district nursing concepts.

You had a central hospital, and then you had outpost centers spread around the county.

And it wasn't just Leslie County.

They weren't looking so much at county lines, when determining their territory, but where people were that needed to be served and their proximity to the hospital.

SUSAN: It was quite a trip to get to any one of those clinics.

She would have two nurse-midwives who would live at each clinic.

And she prided herself that the midwives were taken care of.

So, each one had their horses, and they had a cow in the barn, and they had a person who would come and milk the cow every day and do the maintenance that needed to be done around the clinic.

So, the midwives were primarily responsible for getting up and getting out there and taking care of people.

BETTY: We had this bag in which we carried all supplies that we should need for delivery, and those bags were sacrosanct.

We weren't allowed to use for anything but just the delivery itself.

ELLEN: And accounts by midwives of their practice do show them spending the whole weekend, three days even sometimes, waiting for a child to be born.

And not resenting it because it's part of the profession.

JOYCELYN: Women, they appreciate someone coming into their home and being with them for a period of time.

The nurse midwives are able to really see, recognize and get the kind of help that makes all the difference in the world.

MELANIE: If you were one of their prenatal cases, they would visit you on a regular basis long before the baby was born.

And they were checking blood pressure, they were doing urine samples, they were doing everything that a woman today visiting their doctor for a prenatal visit would get, and this was not the standard of care in most places at the time.

And then they'd provide care after the baby was born.

Every day for ten days they were visiting.

They wanted to make sure these children grew up to be healthy adults, and so they kept very good tabs on all of their patients.

JOYCELYN: And the reason why she was able to have as lower infant mortality rates as she had, is that she stressed good maternal environments for your baby and then you will have a healthy baby and if you have a healthy term baby, they're not likely to die in the first years of life.

And her infant mortality rate was competitive with the best in the country.

SUSAN: For the nurses, it was a very busy lifestyle.

They would get up every morning, they would saddle their horses, and get ready.

They would do rounds all day long and come back.

They talked about very long days, because even when they got back, there were records to keep.

NARRATOR: The nurse-midwives were increasingly bogged down by the demands of the self-reliant regime and more help was needed with the daily chores.

In 1928, Breckinridge savvily solved this issue by creating a program known as the Courier Service.

SUSAN: She reached out to her friends again and said, "Send me your daughters and I'll teach them service."

JULIA: She felt that they needed to have housekeepers so that they could focus on their work.

And the couriers were undergirding that as well.

CARLYLE: The purpose of it was to expose college age students to the challenges and the opportunities in providing healthcare in a rural, underserved community.

And there was a waiting list because all these donors wanted their children to experience what it was like to live in a society where everything wasn't handed to you on a silver platter, and it was a life changing experience.

DOROTHY: The Courier spirit is something that's awfully hard to explain, and it didn't make any difference then and I'm sure it's true today that it doesn't make any difference what your background is, when you get to the Frontier Nursing Service you want to do the best job you can, whatever they ask you to.

JULIA: The couriers were the ones who would guide the cow over the mountain to the next center.

It was the couriers who were taking the medicines from maybe the hospital to the nurse for her clinics.

Couriers could be delivering mail or packages or memos, because in the early years there were no telephones, there was no electricity.

NARRATOR: More often than not, Couriers were tasked with shuttling guests to and from Wendover.

A job not for the faint of heart.

CARLYLE: The only way to get into Wendover was to take a train from Lexington and it stopped several miles from Wendover.

There were no roads, there were no bridges, if you're picking them up you would leave Wendover with a bunch of horses and you'd pick up the guests, get them saddled on horseback or muleback and bring them back to Wendover.

And then when it was time for them to leave you reversed the process.

SUSAN: At one point, they owned over 60 horses.

Because without the horses they couldn't do anything.

And so, she talks about lobbying for money to buy horseshoes, and to have a person to take care of the horses.

People had a hard time connecting the dots to maternal childcare until they learned more about this service, and then they could understand that.

NARRATOR: The service had found its footing.

Mrs. Breckinridge had worked hard to establish her standing and she was resolved to maintain it.

JULIA: Aunt Mary always really wanted to be sure the nurses and the couriers, that they were conducting themselves above reproach.

MARY: As to moonshine, insofar as our nurses were concerned, I told them they were to see nothing, hear nothing, and say nothing.

NARRATOR: By minding only to the business of healthcare, the provider/patient relationships thrived and conditions in an otherwise inaccessible area continued to improve.

The effort was exhausting for these foreign nurses and the eclectic gathering of women found comfort with each other, discussing their shared experiences, often unwinding at Wendover.

DOROTHY: Actually, half the pleasure that we got out of our work was not during the working hours, but simply the contacts and the relationships that we had with all the people who worked there.

SUSAN: Everybody that was local enough was expected to come here and have tea with her at four o'clock.

CARLYLE: And there was a formal kind of tea.

The couriers would serve the tea, they'd bring out the cookies and the cheese for the dogs, 'cause the dogs were always invited to tea.

And she often told a family story.

SUSAN: But, basically it was a time for everybody to tell her what's going on.

What's going on at their clinic, and what's going on at the hospital, and it was a time to share and kind of reconnect.

NARRATOR: By 1929, the Frontier Nursing Service was prepped to expand but the stock market crash and extraordinary drought of 1930 would force it to retract.

MARY: The situation in the Kentucky mountains was rendered even more difficult because of the hundreds of men who came back from the cities after the market crash.

Almost all of them were heads of families, decent, independent people who had never begged in their lives.

And begged now only for work.

NARRATOR: Fundraising circuits continued but even more support was needed as the service now sought to keep its growing community afloat.

Emulating a tactic used by Anne Morgan during her efforts in France, Mrs. Breckinridge employed her younger cousin Marvin Breckinridge to produce a film illustrating Frontier's venture in the mountains.

MARVIN: My cousin Mary wrote me a letter, asking if I would study with a professional in New York, and come down and make a film that she could use in fundraising around the country.

When I made the film, it first was shown in New York in 1931, January, at Mecca Temple, and the New York committee packed the house with people who they were interested in having and Tertius Noble who was a famous musician played the organ, this film of course is silent as almost all films were at that time.

MELANIE: It was kind of cutting edge and exciting, and she was going into people's homes and shooting real footage of what life was like in the mountains.

MARVIN: I came down first in December to get snow scenes and to practice on my camera and also to collect stories for the script.

The camera I used first was a hand-cranked one and the reason the exposure is so terrible in the nurse riding across the wide ford with the snow- covered hills behind is because it was so cold, that I couldn't keep my stroke even, so some is overexposed, and some is under.

So, all of the people in the film, I don't know how many there were, but none was paid a penny for their services.

They were all very willing to participate.

That was their gift to the FNS.

♪ MELANIE: It is a bit sensational.

And even though people living in the FNS territory hadn't seen the film themselves, they read reviews, and they were on edge about being portrayed in these stereotypical ways.

And she gets a lot of feedback (LAUGHS) on what they thought of that publicity.

So, she becomes very careful of scrutiny and publicity, unless it's something that she or her organization is creating.

NARRATOR: A luxury cruise trip was also conceived to generate revenue from donors who might be enticed by a leisurely trip in the name of a good cause.

But, before this plan was fully realized, fate would deliver a major blow.

On a gusty November evening in 1931, Breckinridge had to throw herself from a runaway horse and in turn, broke her back.

MARY: While I lay on stretchers carried by mountain men who, however terrible their injuries, never let on by a sound that they are in pain, I felt that the honor of the Service demanded the same stoicism from me.

So, I joked with them, telling them I would have dieted had I known they were going to carry me.

NARRATOR: Surgeries and a back brace would offer some relief, but Mrs. Breckinridge would require a cane for her remaining years.

Ever more determined, she pushed forward, optimizing her time in convalescence to continue planning.

The Brittanic cruise set sail in February of 1932 with Breckinridge aboard.

The following year a second cruise was planned, but the deepening Depression would dry up any chance of a profit, prompting Breckinridge to map a new course.

MELANIE: The Depression means she has to do more in terms of fundraising, I mean it's an exhausting, grueling schedule that she has as she goes from city to city meeting with women that have the means to support the FNS and charming them, every night having to go out there and earn the money to keep this afloat.

And there's a retrenchment that goes on, the nurses salaries are cut, they are down to bare bones just to survive.

NARRATOR: With strategy and sacrifice, Mary Breckinridge and her unwavering team rode out the remaining years of the Great Depression alongside the community they served.

Even as the nation suffered, maternal health in eastern Kentucky continued to improve and inspire the world.

Modest Appalachian mothers were now equally committed to the cause and opened their homes to global healthcare workers who came to study the outcomes of Frontier's efforts.

1937 marked the 3,000th maternity case and in those first twelve years of operation, only two mothers were lost.

By that time, Frontier Nursing Service had administered over 90,000 inoculations and provided routine medical and midwifery care to an area spanning 700 square miles.

The growing warfront in Europe would claim a large portion of the service's nurse-midwives who were called back to serve their homeland in 1939.

The conflict overseas also effectively cut off the British midwifery training that Breckinridge had depended upon to ready her American nurses for service.

MARY: The Second World War determined the future course of the Frontier Nursing Service two years before the United States entered it.

Our long-deferred plan for the Frontier Graduate School of Midwifery had to be reshaped and put into operation at once.

MELANIE: Now it gives her the opportunity to educate future nurse-midwives to send them out across the country, across the world, and so the Frontier Nursing Service really reaches that goal in maybe not the way that Breckinridge had originally expected to spread these ideas.

For Breckinridge, creating the Frontier Nursing Service was... it wasn't just a project, it was her life work, her lifeblood.

Any financial means she has goes to it.

She lives there, she becomes part of the community, she gives up her comfortable life that she had lived here to embrace some of the challenges of living in a rural area.

At first, she's driven in kind of a simple way by the fact that she's lost her children.

And so, this is her way to continue to mother.

It's also her way of being a Breckinridge and living up to that legacy.

This idea that if you have a lot, you should give back to others.

I think she'd absorbed that message from her earliest days, and this gives her a way to do that.

I think over time though, once she arrives and some of the naivete wears off, she starts to really love these people.

These are her neighbors, these are her friends.

Caring for this community becomes more than just a way to put a band aid on her heart and get over her grief from her children, it becomes her reason for being and it's the only life she knows by the time she gets to her 50s and 60s and 70s.

Her friends are her colleagues in the Frontier Nursing Service, they're her patients, this is her community.

CARLYLE: She was well loved in the mountains by the local people.

And her nurses delivered a lot of them that are still living now.

And she improved their lifestyle tremendously.

BETTY: Riding horseback day, night, summer, winter, anytime.

We have saved a lot of lives and we are still saving them.

JULIA: It has taken a long time for the concept of graduate nurse-midwives to become acceptable, in the country.

I mean, she had the forethought to see the huge need.

It was an experiment.

She wanted to not only to be of service to eastern Kentucky, but she didn't want it to end there.

ELLEN: She wanted it to be imitated all over the country and it really could have been.

I mean, it was a very good idea.

SUSAN: She had people come here from all over the United States and from India, from Great Britain, from Scotland, from the Netherlands, from Australia, come to see the Frontier Nursing Service and how it operated and why were they getting the outcomes that they were getting.

JOYCELYN: And it really is a model which could be used throughout the United States, especially for rural communities.

MARVIN: It was a demonstration of what women could do and women did it!

MARY: And people that we have given experience too, with us and given post-graduate training as midwives have gone to all parts of the rural world.

That's the glorious thing about it, it has worked!

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