the pie of midwifery knowledge
sara wickham
This article was originally published in
Midwifery Today, No 69, Spring 2004, pp 14-15.
Republished with permission.
It is always tempting, when speaking or writing about complex philosophical ideas, to look for simple, everyday metaphors through which to try to make sense of them and then explain them to other people. Often, what you gain in being able to express your thoughts, you lose in attempting to simplify thoughts which should not be simplified, or in trying to put boundaries around ideas which should remain fluid and unbound. This is exactly the problem I face when I talk about “the pie of midwifery knowledge”, yet I still like it as a metaphor to explain to colleagues and pregnant women my thoughts about using different kinds of knowledge in our lives.
Just as we can think of knowledge in quantitative or qualitative terms, there are different ways of thinking about pies. My favourite kind of pie is a round warm apple pie with crust on top, so that's the kind of pie I'll talk about here. A quantitative way of looking at that apple pie is to see it as a circle of 360 degrees which can be cut into quantitative slices, as in a pie chart. Whichever way you measure a circular pie, it always has 360 degrees. That's pretty much a law of our universe as we currently understand it ~ not least because we define a degree as 1/360th of a circle, so by definition we are unlikely to find a circle with fewer degrees! As this shows, there do seem to be some “laws” in our universe which, even though we might refine them as our understanding grows, are relatively fixed.
But we can also look at a warm apple pie as a synergistic creation where the energy of making the pie and the fluidity of the ingredients combine into an experience which is more qualitative. Is there any shop-bought, assembly-line pie which tastes as good as a home made pie, especially one baked by someone who loves you? There is a definite art to baking, and it is difficult to build fixed scientific laws around this. People who love cooking will throw in ingredients without measuring them, and might vary them from pie to pie, for reasons that even they may not understand. One of my friends tried to teach me to make a particular kind of cake a few months ago, and found it quite frustrating that I kept asking her how much of everything to put in. I don't know whether she knew by experience, intuition or some other way, but she didn't use scales and I couldn't figure out her rules! When I asked “how much?” she kept saying, “you just know…” But I didn't!
Some people cook ~ and practice ~ “by the book” and some people do it without the book being anywhere near. It is a matter of debate (both in cooking and in relation to professional knowledge) whether the non-book people once learned the book-rules and then became experienced enough to throw them away, or whether it is possible to bypass the rules completely, but that is another question. No wonder there is such a huge debate amongst some of our medical colleagues about whether the “cookbook” approach to evidence-based medicine is a positive or negative thing!
My own philosophy is that both ways of thinking about pies are equally valid, and that we might learn more by being open to both than by favouring one over the other. Of course, not everybody in out Western world would agree with that ~ many people feel that quantitative, fixed ways of knowing are far more valid than what they term “the fluffy stuff”. Conversely, there are other people who would prefer to live in an entirely “fluffy” world and all but ignore the quantitative dimensions of our existence.
In other words, if we think of all of the knowledge we have around birth and midwifery as existing in a pie, I feel that each part of that pie is just as important as the rest. While scientific research is an important part of the pie, it is not the whole pie. A pie made entirely out of scientific research would, I feel, be very dry and without spice. While science is great for answering some of the questions about the bigger picture, those kinds of knowledge that are more intangible are not only what makes the pie more interesting, but what actually make it work as a whole creation.
Yet neither, I feel, should scientific research be thrown out of the knowledge pie, even though there are aspects of it that may stick in our throats. As individuals, we can sometimes miss the bigger picture and make false assumptions as a result. The first three births I attended as a student midwife were of large babies who each needed help getting their shoulders out. Had I not been able to access, through my experienced mentor and an understanding of “the bigger picture” that this was not usual, I might still be pulling every baby's shoulders out now!
Imagine a woman deciding whether to have a test to see if her baby is the one in a thousand who has a certain condition. Even though statistics alone cannot tell her whether her baby will be the one in a thousand or one of the 999, the knowledge of that population statistic can form an important part of her decision. But her decision is also informed by things that are less tangible; how she and her family feel about the moral issues attached to this, how they might cope with a baby with such a condition, whether the condition is treatable, whether they would rather know and be prepared ahead of time, the impact of the worry caused by waiting for test results and what the practical reality might be for them as an individual family.
Both pies and research studies can be wonderful or terrible. If we taste one piece of terrible pie, we may decide never to eat pie again. Alternatively, we may decide that we will be more selective over whose pies we taste in the future, or decide to add something in or on the side of the pie to make it taste better for us. Every midwife has her own knowledge pie, just as every midwife who bakes will make an actual pie differently. Let's hope, in this age of mechanised factory-production of both edible pies and knowledge pies, that we can continue to celebrate the diversity of pies, respecting the value of the older, tried-and-tested recipes while staying open to the possibility of exciting new ingredients ~ and continue to create pies which make our world a better place!