, even in urban areas. (In 1915, by the way, the US led the industrial world in the number of childbirth deaths per 1,000. In 1932, when Twilight Sleep was still the principal feature of hospital childbirth, that figure had risen.)
Even though urbanizing and ever-more-industrializing America began to make greater and greater use of physician-attended childbirths in hospitals in the 1920s, as a practical matter the women in rural areas of the US were a population markedly underserved by professional medical care. Institutional health care was not merely unaffordable for women in remote areas but was inaccessible as well. Into this situation in 1925 came one Mary Breckinridge, a nurse-midwife trained in England, who established what was called the Frontier Nursing Service in the Appalachian Mountains of southern Kentucky. According to Wasson (2000), Breckinridge was responding to found conditions: the shortage of physicians in rural Kentucky at the time. Her original vision was that a Family Nurse, supervised by an area physician, would be the primary care provider for the people there. Midwifery appears to have come to the fore, more or less the practical product of the evolution of medical need:
[Midwives] were the only care providers to have contact with many families [and] began to offer care to families beyond the intrapartum period. . . . [T]he nurse midwives treated minor medical problems of the family and instructed family members in such matters as personal hygiene, nutrition, sanitation, and disease prevention (Wasson, 2000).
The effect of this positioning of Family Nurses in the scheme of rural medicine was to create "a new model for rural maternity care" (O'Mara, 1999). Embedded in that was an ethos of care, as ind
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