Mary Bristow Willeford: Frontier Nurse-Midwife, Educator, and Researcher

By Professor Janet L. Engstrom, PhD, APRN, CNM, WHNP-BC, CNE and Professor Anne Z. Cockerham, PhD, APRN, CNM, WHNP-BC, CNE

In this year of centennial celebration of the founding of the Frontier Nursing Service, it is fitting to honor the pioneers who helped build the nursing service and lay the foundation for Frontier Nursing University. Mary Bristow Willeford (1900-1941) was one of the first nurse-midwives to join the Frontier Nursing Service in August of 1926 and became one of the first Assistant Directors of the organization, playing a key role in the development of the clinical nursing service and the university.

Born in 1900, Willeford had unique educational opportunities for a woman at that time in rural Texas. She earned a teaching certificate from The San Marcos Normal School in 1918 and a baccalaureate degree from the University of Texas in 1920, graduating near the top of her class. Willeford had planned a career in medicine and began preparatory work at Johns Hopkins University but switched to nursing and graduated from the prestigious Army School of Nursing in 1925. The Army School provided the opportunity for students to learn military health care, protocol, and etiquette, and provided a variety of clinical experiences in civilian settings, including preparation as a public health nurse. Willeford took advantage of the opportunity to study public health nursing which included clinical experiences with Henry Street Visiting Nurses in New York City and taking courses in public health at Columbia University. After graduating from the Army school in 1925 and passing the nursing licensure exam, Willeford traveled to England with a classmate, Gladys Peacock, to complete midwifery education at the York Lying In Maternity Hospital. Both nurses returned to the United States to join Mary Breckinridge in southeastern Kentucky at the new rural nursing and midwifery service that would become the Frontier Nursing Service.

Willeford and Peacock worked with the FNS during its early development and expansion phase. Although the FNS was primarily focused on reducing maternal and infant mortality and improving child health, accomplishing those goals required that the nurses provide a broad program of public health services including preventative care such as vaccines, sanitation, home safety, and health education. Since there were almost no other professionally trained and licensed healthcare providers in the area, the nurses also provided care for illnesses and injuries. Thus, the nurses were called upon day and night to attend births, illnesses, injuries, and deaths. The nurses also cared for the families’ pets and livestock, vaccinating the dogs for rabies and treating illness and injuries in the livestock that were needed by the families.

The nurses’ work was made more challenging by the rugged mountain terrain where the families lived. There were almost no roads, so the nurses traveled by horseback on mountain trails, carrying all their supplies in their saddlebags, which weighed about 40 pounds. Sometimes the nurses had to travel part of the journey on foot and carry their saddlebags across a wood and rope bridge above a river or ascend a hillside too steep for their horse. Beyond the physical demands of their work, the nurses also had to respectfully and creatively work around the families’ limited access to food, clean drinking water, and other resources. The FNS service area was one of the most impoverished areas of the United States and the nurses had to be tremendously resourceful to help their patients stay healthy and nourished.

Although Willeford and Peacock were instrumental in building the clinical nursing practice, they also played important roles in the administration of the new nursing service. Shortly after their arrival in 1926, they were assigned to oversee the building of the first district nursing center at Beech Fork and would go on to build four more nursing centers at Red Bird, Flat Creek, Brutus, and Bowlingtown. When building a nursing center, the nurses were responsible for overseeing all phases of the construction and, at the same time, begin caring for patients and developing the patient caseload for the new center. The nurses also had to build community relationships and identify people who would serve as the governing committee for the center.

In addition to Willeford’s clinical and administrative skills, the FNS also recognized her potential as an educator. From its inception, the FNS had planned to train health care professionals to provide maternal-child health services, including midwifery, in rural and underserved areas. Willeford was the ideal candidate to lead the educational initiative since she already had a teaching certificate and a baccalaureate degree. In 1927, Willeford was sent to Teachers College, Columbia University to complete a master’s degree in public health. The following year, she was sent to England to undergo training as a midwifery educator and earned a certificate as a midwifery tutor. In 1930, Willeford returned to Columbia University where she earned a Doctor of Philosophy degree in educational research in 1932. Her advanced educational opportunities were unusual at that time, when the average American had only 8 years of education, almost all nursing education took place in hospital-based nursing schools, and master’s and doctoral degrees were a rarity.

Willeford became one of the first nurses in the United States to earn a doctoral degree, when few doctorates were awarded nationwide and only a small percentage of the recipients were women. Her dissertation examined the income of 400 families in Leslie County, where the FNS was based, and determined that most families could not afford basic healthcare and that nursing services such as the Frontier Nursing Service were an effective solution. The dissertation was recognized for its contributions to public health, healthcare economics, and Appalachian history. The dissertation also included a curriculum plan for a model nurse-midwifery educational program in the United States, and that curriculum plan was implemented at Frontier when it opened its nurse-midwifery educational program in 1939 and at the other early nurse-midwifery programs such as the Maternity Center Association and the Tuskegee Institute.

Willeford was appointed as one of the first Assistant Directors of the Frontier Nursing Service and oversaw much of its records systems documenting the processes, outcomes, and cost of care. She was also sent outside of the Frontier Nursing Service to assess maternal-child health resources in other remotely rural areas including the Ozark Mountains in Missouri and Arkansas, and several American Indian Reservations in the Southwestern United States. Based on her findings at the Indian reservations, the Frontier Nursing Service was asked to prepare two American Indian nurses as nurse-midwives. The nurses spent a year at Frontier learning their new role and learning nurse-midwifery using the curriculum designed by Willeford.

In 1938, after 12 years with the FNS, Willeford left the FNS to gain experience working at the state and national level to improve maternal-child health. Willeford accepted a position as a maternal-child health nursing consultant to the California Department of Public Health, and she traveled throughout the state educating nurses about maternal, infant, and child health.

Willeford completed her work in California in 1940 and then joined the United States Children’s Bureau as a public health nursing consultant. In her new role, Willeford oversaw the funding of new and established nurse-midwifery educational programs. She also served as the Children’s Bureau representative responsible for the establishment of the Tuskegee nurse-midwifery educational program which was established to educate African American nurses to work in rural, underserved areas with high maternal-infant mortality. At the Children’s Bureau, Willeford also conducted research, worked with the state health department to improve the quality of midwifery care, and evaluated maternal-child health services in Puerto Rico.

Despite the demands of her work, Willeford remained in close contact with and visited her friends at the Frontier Nursing Service and served on its Nursing Advisory Board. The plan had always been that Willeford would gain experience at the larger system level and then return to Frontier, likely to be Mary Breckinridge’s successor. However, Willeford became seriously ill and died on December 24, 1941. In the final days of her life, nurse-midwifery pioneer, Rose McNaught, was at her bedside, reading aloud from the latest Quarterly Bulletin of the Frontier Nursing Service and talking about their time working in the mountains. Willeford told McNaught that her happiest time had been spent in the ‘hills’. Although Willeford and the other pioneering Frontier nurses are gone, and the clinical work of the Frontier Nursing Service has been replaced by larger health systems, the heart of the Frontier Nursing Service lives on in the Frontier Nursing University and its alumni, who are no less brave than the original pioneers. The innovation of the ‘nurses on horseback’ is imprinted on the educational program and its alumni who have gone on to provide innovative health care all over the world. The saddlebags have been replaced by book bags and computer bags, the nurses on horseback have changed to nurses online and on campus, and the work of the organization has shifted from providing direct nursing care to people in rural and remote areas to preparing advanced practice nurses to provide care in rural and underserved areas everywhere. The work goes on.