Zen and the Art of Motorcycle Maintenance has replaced Arthur Ransom’s The Picts and the Martyrs as my desert island book. My daughter says that no one ever should be told that they ought to read a book but my son recommended ZAMM when I was agonising over two seemingly intractable problems – my mind was spinning off in so many directions at once that I feared for my sanity. I was frustrated by my apparent failure to wow the NHS into giving women a useful piece of kit to encourage them to keep off the bed for labour and birth, and in despair that I would ever be able to interest health professionals in a new science of birth – rather than being a mere passenger in a disembodied uterus, the baby and the mother might both have crucial parts to play in the action.
What Persig was trying to do in ZAMM was to reconcile the classical and the romantic, reason and emotion, the Cartesian dualism that pervades modern thinking and divides art from science. It seems to me that the apparent differences between obstetrics and midwifery divide along those very lines. Obstetrics claims to be driven by reason, science and technology, whereas midwifery is seen as the Antiscience, touchy feely emotion-driven care which puts mother and baby at risk – despite the fact that statistics show that midwifery care, particularly from a known midwife, is just as safe for the baby and safer for the mother – and I believe for her mental health and therefore the health of family life.
Persig was struck by the fear or even contempt that some have of technology – how could there possibly be an art to motorcycle maintenance? But unless we can learn to see the art in technology it becomes our master and us its slaves; we live in a technological world, we must embrace technology not run from it. At the same time we cannot live by algorithms, life is not just a matter of following the steps laid down by the manuals to obtain the desired result. Current manuals of motorcycle maintenance fail to tell you what to do when you encounter a sticky screw which resists all attempts to remove it. In order to get from step 1 (remove screw) to step 2 (lift off engine cover) you have to insert an additional step not mentioned in the manual. You have to be inventive and use your wits and insert step 1a (think of a way of removing stuck screw and remove it). This is where the art comes in. You can’t do everything by the book because no book can cover absolutely every eventuality.
I have to admit to an antipathy to machines that go ‘ping’. For me the technology of fetal monitoring epitomises the divide between obstetrics and midwifery. Sometimes it seems that the EFM printout is the only thing important in maternity care – certainly that is what the lawyers and administrators of insurance like to tell us. EFM may well serve their purposes but research shows that it benefits neither mother nor baby, it does nothing to reduce perinatal mortality or cerebral palsy rates and it increases caesarean section rates. Furthermore, I would suggest that it puts a technological barrier between mother and caregiver and blinds the caregiver to other clues to the progress of labour. For my part, I would prefer the simpler technology of the Pinard stethoscope which makes a more direct connection between the midwife’s ear and the baby’s heart sounds, with only the barrier of the maternal abdomen in between. I want the midwife to use all of her senses in assessing the condition of mother and fetus. Concentrating her efforts on the comparison of two graphical representations made by a machine falls far short of quality care in labour.
And, for Persig, Quality and Care are the means of reconciling technology and art.
So my aim is to do for birth care what Persig did for motorcycle maintenance, to reconcile the seemingly opposing philosophies of birth espoused by midwifery and obstetrics. Midwives do not have a monopoly on the art of birth and obstetricians do not have a monopoly on the science of birth. The interface is physiology, the natural science of birth. I started my own journey towards understanding birth as a psychologist, looking at the interface of mind and body – stress hormones. I ended up with a new model of uterine function which emphasises the importance of active birth. We can give Quality Maternity Care only when we understand how mothers’ and babies’ bodies work together during labour and do all we can to honour and respect this partnership.