01:00 AM EST on Monday, January 23, 2006

THE ANCIENT Scottish town of Brechin lies a few miles west of the North Sea port of Montrose. Brechin has not achieved much fame in its lengthy existence but sometime in the early 18th Century a handful of its residents ventured west across the Atlantic to establish homes in the wilderness of Kentucky. These pioneers, using the family names Brechinridge, Breckinridge or Breckenridge, adapted readily to the hardships of the American frontier, and today there are prospering towns and cities bearing the name Breckenridge in six states and one Canadian province.

There was, for example, John Cabell Breckinridge (1821-75), born in Kentucky, who became a leading state legislator and a military leader during the Mexican War. He served in Congress from 1851 to 1855 and was then elected to the vice presidency of the nation on the James Buchanan ticket. He was this nation's youngest vice president. In 1860 he was selected to run for the presidency by the pro-slavery section of the Democratic Party. He lost the election to an obscure congressman from Illinois, named Lincoln, but then served in the Confederate Army, escaping to Cuba at the completion of the Civil War.

Yet another Breckinridge served under President Grover Cleveland as ambassador to the Imperial Court of Nicholas II, Tsar of Russia. His daughter Mary was born on Feb. 17, 1881, in Tennessee. Her education was principally conducted by private tutors, in both Washington and St. Petersburg, with additional schooling in the private academies of Switzerland and Connecticut.

Mary Breckinridge traveled extensively while learning the niceties of upper-class social life. At 23, she married an American attorney. But two years after their marriage, Mary's husband died, of acute appendicitis. At 26, seeking a career, Mary attended St. Luke's School of Nursing, in New York City, graduating in 1910 with her license as a registered nurse. Mary married a second time, in 1912, then bore two healthy children. Both children tragically succumbed to infectious disease at an early age. Mary then devoted the remainder of her life to the nursing care of women and children.

Mary Breckinridge volunteered to serve with the U.S. troops in France during the terrible years of World War I. While in military service, she witnessed nurses with more extensive education than hers -- nurses with greater skills and certainly with a greater sense of purpose and authority. In her words, "After I had met British nurse-midwives, first in France and then on my visits to London, it grew upon me that nurse-midwifery was the logical response to the needs of the young child in rural America. My work would be for them."

At the completion of hostilities on the Western Front, Mary returned to New York to study public-health nursing at Columbia University. Upon graduation she elected to go to eastern Kentucky to confront the formidable health problems of this rural, mountainous region. Eastern Kentucky was then an impoverished territory, with few roads, no licensed physicians, and no hospitals.

Mary Breckinridge believed that she could succeed in this difficult terrain, populated by those disparagingly referred to as hillbillies. The roads were inaccessible to automobiles, so she resorted to horseback. For months she rode or hiked through an endless succession of poverty-stricken towns, typically situated in the narrow valleys between steep hills, places called "the hollers." She found that most Appalachian women lacked prenatal care and were delivered by self-taught local midwives.

The average woman in Kentucky's hill country had nine children, none of whom received anything remotely resembling proper neonatal or pediatric care. Husbands were usually employed in the regional coal mines. Their ailments included rampant tuberculosis, silicosis, malnutrition and pervasive alcoholism.

Mary Breckinridge then hastened to London, where she enrolled in a school of nurse-midwifery. She then traveled to Scotland, to observe and work in its decentralized community midwifery system, which provided the bulk of maternity and neonatal care in the rural Highlands.

She returned to Kentucky with a plan, modeled on the Scottish system, using teams of nurses on horseback. And so, in 1925, Mary Breckinridge established the Frontier Nursing Service, as a nonprofit health-care enterprise providing maternity and pediatric service for about 700 square miles of rural southeastern Kentucky. Within a few years she had raised in excess of $6 million, to underwrite her vision of rural health care, including a hospital, in the town of Wendover, as a sanitary facility to deliver the babies of the region. The Frontier Nursing Service charged an annual fee per family, of $2 -- to be paid in cash or groceries.

What have been the results of Mary Breckinridge's efforts in Kentucky? Her Frontier Nursing Service nurses (called "nurses on horseback" by the newspapers) served the region so well, so diligently, that the survival rate of both the women giving birth and their infants soon rivaled the commendable rates in the cities of western Kentucky. Indeed, of the first 17,053 births attended by these nurse-midwives, only 11 maternal deaths were recorded -- a remarkable achievement.

Mary Breckinridge's accomplishments also included the establishment, in 1939, of the first American school of nurse-midwifery, in Hyden, Ky., as well as a similar school in New York City.

She continued her assertive direction of the Frontier Nursing Service until her death, in 1965.

And the Frontier Nursing Service today? As before, some of its nurses come from Britain, in the service's tradition of employing only qualified midwives, but nowadays sturdy SUVs have replaced the horses. The service now supervises an elegant hospital, named for Mary Breckinridge, and four regional maternity-health centers in the Kentucky hill country. Nurses and public-health officials from other countries regularly travel to Wendover, to learn how to design rural-district health centers. And fourth-year medical students at Brown University may spend up to three months in rural service supervised by these indomitable nurse-midwives.

Stanley M. Aronson, M.D., a weekly contributor, is dean of medicine emeritus at Brown University.