An example is the rising caesarean rate. This varies considerably from country to country, indicating that social and cultural factors play just as much of a role as medical factors in determining the use of medicine. In parts of some countries such as Brazil the rate is as high as 85–100% with rates of 47.7% not being uncommon (Ratner 1996).

Nationally in the UK the rate is 23% (in 2003–4; RCOG 2004), in Canada 25% (Anderson & Lomas 1984, but still approximately this rate), while in the Scandinavian countries the rate is 10% (Wagner 2000). In 1985, the WHO suggested that 10–15% should be the highest rate. In the work of Ina May Gaskin, an American lay midwife who specialises in supporting natural births, fewer than 2% of women needed a caesarean. No one knows what the optimal rate should be, although Mukherjee (2006) still feels that the rate should be kept between 10 and 15%.

There is increasing concern about rising rates in medical circles as well as among advocates of natural birth, as unnecessary caesareans carry health risks to both woman and fetus.

The reasons for the spiralling rate are multifactorial and include:

Even in what are recorded as ‘normal’ births there is a high degree of intervention. In a recent study in the Trent region of the UK in over 60% of the 956 deliveries recorded as ‘normal’ or ‘spontaneous’ (i.e. excluding instrumental or caesarean section deliveries) interventions had occurred. These included amniotomy, induction, augmentation of labour, episiotomy and epidural anaesthesia. In about a third, induction or augmentation of labour had taken place, while in 89% amniotomies were performed before the cervix was fully dilated (Downe et al 2001). There is current debate about how to ‘adopt the truly scientific approach of seeking the evidence base of all methods old and new’ (Henderson & Macdonald 2004: 1096).

Some practitioners argue that we are beginning to forget what ‘normal’ birth is and that anything which interferes with the natural process of birth can be considered an intervention. This includes vaginal examinations, telling the woman to push (or not to push if the obstetrician is not available), and monitoring the fetus (especially electronic fetal monitoring), because they rely on external sources for assessing and progressing labour and because they may interfere with the interaction between the woman and her baby.

An assessment is made of how ripe the cervix is using the Bishop score. This is a way of grading softness and effacement.

Bodywork can often be continued. Many people assume that medical induction of labour happens quickly but it often involves a lot of waiting around and medical staff are reluctant to give any pain relief because they do not know how long it will take to get labour established.

Bodywork will not only help the woman be more relaxed while waiting, thus helping her to be more likely to go into labour, but this waiting time can also be used to work on the labour focus points as much as possible to try to get labour going naturally. Once the woman has started on whatever regimen she is having, it is still possible to continue to work the labour focus points.

This is nitrous oxide inhaled through a mask. It provides partial relief of pain through its sedative effect. It is used fairly extensively in the UK but not so much worldwide, as in some countries such as Canada its use has been associated with an increase in abortion in caregivers.