Maternal mortality often is defined as the pregnancy-related death of a mother leading up to and extending a year from giving birth. It’s a subject many people are reluctant to address, yet the numbers from multiple organizations, like the Centers for Disease Control and Prevention and the World Health Organization, beg for a closer look.
In some maternal death cases, there are obvious pre-existing, chronic health conditions such as hypertension, diabetes or obesity. But in other cases, rising maternal mortality rates can be attributed to social, cultural and economic factors.
“Our maternal mortality rate was seven [maternal deaths] per 100,000 [live births] in 1985, and today it is 28 per 100,000. Our outcomes are getting worse instead of better, and by ‘our,’ I mean the United States,” said Susan E. Stone, the president of Frontier Nursing University, a higher education institution begun in 1939 as the educational branch of the Frontier Nursing Service. For 80 years, FNU, soon to be based in Versailles, has educated and equipped registered nurses in the care of mothers, children and families in rural areas.
Training to Beat the Odds
The Frontier Nursing Service began in 1925 under the passion and direction of Mary C. Breckinridge. The second of four children born into a nationally politically prominent family, Breckinridge trained as a nurse in the United States and abroad, earning her registered nurse degree in 1910. After the deaths of both her infant daughter in 1916 and her 4-year-old son in 1918, she determined to find a way to help children and their families through nurse-midwifery. At that time, infant mortality rates were nearing 100 deaths per 1,000 live births, a statistic that pierced Breckinridge’s heart in a personal way.
With money bequeathed to her via her mother by her Kentucky-born great-aunt, Breckinridge set out to build a bulwark of health in one of the poorest and most remote parts of the Commonwealth: Leslie County. Breckinridge and her nurse midwives rode horses through rivers, up mountainsides and every place in between. They carried saddlebags filled with supplies and built bridges of respect between medical personnel and mountain folk.
Breckinridge gave a practical reason for launching her mission in the eastern Kentucky mountains in her 1952 autobiography, Wide Neighborhoods.
“Not only was there no reason why the Kentucky mountains should not be chosen, but we had the best of all reasons for choosing them, namely, their inaccessibility,” Breckinridge wrote. “I felt that if the work I had in mind could be done there, it could be duplicated anywhere else in the United States with less effort. From the beginning I had the wish to do the work so well, and to keep such accurate records of it, that others would study it, be trained in its techniques, and then, in other remotely rural parts of our own and other countries, repeat the system we used. It would be possible for us to reach only a few thousand children directly, but hundreds of thousands of children could be reached by others because of us.”
Nearly 100 years later, Breckinridge’s dream is still being realized through the graduates of Frontier Nursing University.
Training to Better the World, One Community at a Time
FNU is listed in the top 50 US News & World Report Best Online Graduate Nursing Programs, with its Family Nurse Practitioner Program earning the No. 6 spot in the US News & World Report Best Graduate Nursing Schools. Over the years, the university has won awards and earned accolades, but perhaps one of its most significant honors is knowing university graduates are on the front lines saving women and children.
“Back then, the mission was a list of objectives: safeguard the lives of mothers and babies; provide and prepare trained nurse midwives for the rural areas of Kentucky and other areas needing medical care; to give skilled care to women in childbirth; to give nursing care to the sick of both sexes and all ages,” Stone explained. “Mary knew that, to provide primary care to that person, you really had to pay attention not only to that person but to the family and to the community in which they lived. And I believe those are core components of what we do today and what we teach our students.”
In the beginning, nurse midwife education took place on the mountainside. Nurses traveled from their homes to Hyden, where they would live and learn from Breckinridge and British nurse midwives who had been recruited to teach specific midwifery skills. As World War II brewed in Europe, many of the British nurses returned home. By then, Breckinridge had a large enough, highly skilled staff to continue teaching new nurse midwife recruits how to serve in rural areas. By 1939, the Hyden-based Frontier Nursing University was an official institution.
In 1989, FNU started a pilot distance learning correspondence course to educate future nurses. The reason behind the switch to distance learning was in line with Breckinridge’s core mission. Instead of recruiting nurses to leave their families, stay on campus for coursework, and then complete their clinicals in the designated eastern Kentucky health districts, FNU made a bold move that allowed nurses to remain in their own communities.
Stone knows firsthand how well the distance learning model benefits nurses and their home communities.
“Frankly, I lived way in upstate New York,” she said. “I had three small children, and I was looking at a way to be a nurse midwife. I had three options. I could travel to New York City for a residential program, which was more than six hours away from me. I could wait until the littlest one went to kindergarten. Then, Frontier came out with this distance model.”
Stone graduated from FNU in 1991. It wasn’t long before she returned as president of the institution that had trained her.
The distance learning model works like this: Registered nurses who are accepted into the program travel to the Hyden campus for a one-week orientation; then they return to their home communities, where they study online for about a year. Students return to Hyden for another week on campus before going back to their home communities to complete their clinicals. Each student is assigned to a regional clinical faculty member, who provides support and guidance and oversees the students with their clinical coursework.
Throughout 2019, FNU has scheduled 20 orientation sessions spread out over quarterly academic terms, each geared to the different programs and degrees. The university offers a doctor of nursing practice and a master’s degree program with four specialties—nurse midwifery, family nurse practitioner, women’s health care nurse practitioner and the rapidly growing psychiatric mental health nurse practitioner.
One of the reasons why the distance program works, Stone said, is that it enables students to be close to the people they will one day serve. After all, who knows the social and cultural habits of a community better than the people who live there?
“We need health care workers who are going to be in our communities, paying attention to the social determinants, going to the rural areas,” Stone said. “When people understand deeply the culture of the people they are serving, that’s the best outcome.”
Even with the distance method and the positive numbers that prove it works, people can’t be helped if there aren’t enough nurses to go around. Stone said the school turns away at least 50 percent of those who apply. FNU simply doesn’t have the space in Hyden to expand enrollment.
“Our current location is remote and difficult to get to,” Stone explained. “We rent a bus to go to the airport and then transport our students 125 miles down to eastern Kentucky. It was one thing when we were doing 25 students four times a year back in the early 2000s, but with the numbers that we are bringing in and out, we are overusing the facilities.”
Facilities that are 100 years old in most cases.
Six years ago, the FNU Board charged Stone and her team with finding a solution.
Training a University to Move
Because of FNU’s academic rhythm, there was no need for a large, sprawling campus. Instead, Stone said she looked for rural simplicity.
“I knew it had to be in a rural area. It had to be in a rural ZIP code. It had to have a rural feel to it, but I wanted it to be accessible to the airport if possible,” Stone said.
At the same time, the Kentucky United Methodist Children’s Home in Versailles was looking for a change. It needed to move closer to community-based support systems to meet the changing needs of its young clientele. The Children’s Home sold its Versailles campus to FNU, and a new era—still working toward a decades-old mission—was born.
Just 10 miles from the Blue Grass Airport in Lexington, the new FNU campus will accommodate students when they come for their on-campus sessions. It will be able to house students and faculty, serve meals from a cafeteria, use an auditorium, and host clinical simulations in a classroom building.
“We knew this was an environment we could build into and relocate to and be the home for Frontier,” Stone said.
Renovation and construction should be complete by the summer or fall of 2020. At that time, the university activities will be moved north but still within reach of any rural area.
The Tale of a Nurse Midwife
The Frontier Nursing Service provided nurse midwifery, child hygiene, dentistry, emergency surgery, nursing and general medical care.
Nurses rode anything they could get their hands on, carried medical supplies in saddlebags, forded creeks and rivers in every type of weather, broke through dense brush and superstitions, and saved countless lives.
They covered 700 square miles and then some. The Hyden Hospital and Health Center was to be the “palm” of the medical hand, with outpost clinics spreading like fingers into the mountains.
Mary Breckinridge invited Scottish Highlander Sir Leslie MacKenzie to deliver the dedication address in June 1928:
“In all reverence, I dedicate this hospital to the service of this mountain people. The act of dedication will have consequence beyond all imagination. It will evoke responses along the many hundred miles of these mountain frontiers and among the millions of their people. The beacon lighted here today will find an answering flame wherever 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.”*
Filled with prescience, this dedication foretold a reality that beckoned nurses from as far away as India to come and see, learn and then go and serve.
It was a call answered by a woman who wishes only to be known as Gertrude.
For Such a Time as This
At the same time that Breckinridge was settling the FNS into the Kentucky mountains, Gertrude took her first gasps of air almost 600 miles north in a West Milton, Pennsylvania, parsonage. Raised in the old German Baptist “Dunker” tradition, Gertrude was no stranger to the work done by human hands.
She planted potatoes in her grandfather’s fields when she was only 4. By the time she graduated high school, World War II was on. Gertrude worked in a factory and a post office. She dug gardens, and chopped and racked wood. Whatever her hands found to do, she did.
She entered the Geisinger Medical Center nursing program in Pennsylvania in 1952 and graduated with her RN in 1955. She stayed on at Geisinger for a year after her graduation, teaching and helping nurses do clinicals, but a large part of her heart was already in Appalachia.
“You see, I picked up a book from the library one night, Nurses on Horseback, and I read it and I thought, ‘Oh! That’s for me. Why should I be in a hospital when I could be on a horse?’ ” she said.
The day Gertrude arrived at Hyden Hospital, she checked in with British nurse midwife and hospital matron Betty Lester. Gertrude took the night shift at the hospital in the general ward at first.
Following the prescribed FNS medical and midwifery routines, Gertrude made her rounds on horseback initially and by jeep in her latter days at FNS.
She worked on the philosophy she learned from an instructor: “You are a nurse. If there isn’t a way, make one.”
“I never forgot that, and I made many a way,” she said.
Gertrude delivered more than 1,000 babies during her career. She never lost a mother or an infant in all those births.
She served at the hospital and outpost clinics in places like Beech Fork, Red Bird, Flat Creek, Confluence, Leatherwood and Brutus. She crossed Hell-fer-Sartin Creek more times than she can count.
From 1956 until 1972, Gertrude served in some capacity with the FNS. She climbed into abandoned coal mines to fetch coal for her fires. She heeded Breckinridge’s advice and never once spoke of moonshine, religion or politics. Her clinics operated efficiently and effectively. She cured children of worms, treated all manner of wounds, was shot at, went hungry and was charged by a milk cow named Feisty.
As she sat in the main room of her modest central Kentucky home, she told a story.
“There was a man came and stole my hay. He thought he was doing me something wrong, but I was thankful,” she said. “The rats had got into the hay, and my horse wouldn’t eat it. Later, I delivered his baby. I had stopped to see the lady, and the little girl came up to me and said, ‘Tomorrow is my birthday.’ ”
She paused in her narrative and searched for the words of a poem, trying a few times to get the phrasing just right. After several moments, she went on in a sing-song voice, quoting a portion of “The Mountain Whippoorwill” by Stephen Vincent Benet.
Born in the mountains, never raised a pet, Don’t want nuthin’ and never got it yet.
“That’s about how it is. I said, ‘Well, maybe we can get you a little baby sister or brother for your birthday.’ About three o’clock in the morning, I went up and delivered a baby girl. I handed the little girl the baby and said, ‘Here is your baby sister for your birthday.’
“The next year, there was a fire. There were no fire trucks, nothing like that. The little girl that I delivered, the little girl that wanted her, and one other child burned to death in the fire.”
That was the way of the mountains. Gains and losses and life in between. But given a chance, Gertrude said she would do it all over again.
“I’d go back in a minute, and they wouldn’t have to pay me a cent,” she said. “I don’t know how you feel about Jesus Christ, but He has been with me, and He has put me exactly where He wanted me. I know He saw that potential in my life. He made my path, and I know I had to follow it. And so, I did.”
All the way into those wide neighborhoods.