Davis’ observations about CNMs, hospitals, and birthcenters, however, appear to be somewhat biased. Herdefinition of a midwife excludes nurse-midwives or any-one attending births in a hospital setting, making itdifficult for families to make fully informed choicesregarding their birth options.

Much of Davis’ book is based on oral histories andanecdotal experiences. Journals and texts are quotedwithout page notations, and references are scant. Someof Davis’ management guidelines are disputable and/orinaccurate, as exhibited by the following examples:1) when inspecting the perineum during repairs, themidwife is instructed to check the “levator ani muscleencircling the anus” (p. 152); 2) Rhogam is said to be“harmful to the fetus” and its use controversial (p. 31);3) wetting suture with Betadine prior to use to make itmore flexible is recommended; 4) she states that thepurpose of a-fetoprotein screening is limited to “detect-ing neural tube defects only” (p. 32); 5) a questionableclinical maneuver is mentioned for correcting asynclit-ism, in which the sagittal suture is centered, and 6) herdescription of fetal heart rate patterns is confusing anddisorganized. She describes variable and late decelera-tions as though a fetal monitor strip is being interpretedalthough the information is obtained solely from listeningwith a fetoscope or doptone. In addition, non-stress tests(NSTs) are summarily dismissed as being unrelated tofetal outcome and clinical assessment is equated tobiophysical profiling. She further claims that even smallchanges in amniotic fluid volume are detectable by themidwife’s exam.

Davis gives examples of the successful use of alcoholduring pregnancy and labor as an aid for relaxation andto stop preterm labor. Although the dangers of a glass ofalcohol under these circumstances are unknown, recom-mending alcohol use today is considered professionallyirresponsible and dangerous. A caveat discussing thepotential implications for the fetus is indicated. This issueprovoked heated discussions among the reviewers.

Heart and Hands is recommended as a supplementto other texts. Elizabeth Davis gathered an enormousamount of thought-provoking material in this edition.Her area of expertise in the art of midwifery is unques-tionable, and for her generosity and willingness to share,all midwives can be thankful.

Dr. Susan Love’s Hormone Book—Making InformedChoices About Menopause. By Susan M. Love, MD,with Karen Lindsey. New York: Random House, 1997.362 pages. $25.00, hardcover.

Reviewed by: Karen Burgin, CNM, Associate Editor,JNM; Nurse-Midwifery Associates, Brooklyn, New York.

Dr. Susan Love, the breast surgeon and women’s healthadvocate, with her co-author, Karen Lindsey, has written

an impressively researched, readable, and intelligentguide for women facing the decision of what, if anything,to do about menopause. Readers are forewarned to beprepared for the current stance of most ob/gyn physi-cians, reinforced by the media, that virtually all meno-pausal women need hormone replacement therapy. Dr.Love’s purpose in writing this book is to help womenmake informed decisions about the many available op-tions, both hormonal and alternative, with a clear mes-sage that those who choose alternatives need not fearthey are getting second rate care.

The author states from the beginning that she will notprovide definitive answers. Instead she offers readers avariety of tools to help them decide for themselves, andalternatives for those who choose not to use hormones.She feels that hormone therapy may well be the rightchoice for many women, but she cautions against auto-matic acceptance of the knee-jerk reaction of manyphysicians to hand out prescriptions for hormones with-out considering individual women’s needs, risks, andlifestyles. As a physician whose life is devoted to wom-en’s health care in a field other than ob/gyn, she has theadvantage of an objectivity and a healthy skepticism lessoften encountered in gynecologists. Also as a skilledresearcher, she has the ability to help women siftthrough the sometimes contradictory, incomplete, andconfusing studies routinely quoted to promote each newindication for prescribing hormones.

The medical establishment and the drug companiestake their share of criticism in the chapter entitled “TheMedicalization of Menopause.” Love feels that present-ing menopause as a pathologic state is “an ugly anddangerous notion,” but one that makes money both forphysicians and for pharmaceutical companies. She chas-tises big business for marketing eternal femininity and forplaying on the fears of aging and death so prevalent inour society. She cites the huge investments of drugcompanies in medical research, their contributions tomedical symposia and conventions, and their influenceon the media.

Love’s extensive experience with researching andtreating breast cancer has given her a deep respect forthe power and mystery of hormones; she cautionsagainst making assumptions about hormones’ effectswithout large-scale randomized clinical trials. To date, nosuch trial has been completed. Common sense, shewarns, was the rationale used when diethylstilbestrol wasassumed to prevent miscarriage, and when unopposedestrogen was widely prescribed, later to result in manycases of endometrial cancer. Common sense is onceagain the rationale given today for long-term use ofprogestin, as in continuous hormone therapy, with as yetno study proving its safety. The term “replacement,”Love feels, is inappropriate when referring to hormonetherapy; it is incorrect to imply that something is lost and

Journal of Nurse-Midwifery • Vol. 44, No. 3, May/June 1999 331

must be replaced. All hormones administered to womenmust be respected as the drugs they actually are—eventhose labelled “natural” are, in fact, exogenous sub-stances not naturally present in the female body.

It will come as no surprise that Love’s philosophy ofcaution leads to some recommendations not in harmonywith current medical practice. One such suggestion isthat the initiation of hormone therapy for those at riskcould well be delayed, perhaps by 10 years followingmenopause, due to the fact that the leading indicationsfor preventive use of hormones (osteoporotic fracturesand myocardial infarction) cause mortality primarily inthe elderly. Her thought on the use of hormones as apossible prevention for Alzheimer’s disease illustratesher point: “Is it worth endangering your life to avoid adisease you probably won’t live long enough to get in thefirst place?” She is firmly convinced by breast cancerstudies, in particular by the 1991 data from the Nurses’Health Study of 121,700 women, that the increased riskof breast cancer is a very real one, compounded by theaddition of progestin to the mix. She unequivocallyopposes the use of hormone therapy for breast cancersurvivors. She also believes that the scant research ontestosterone makes its use a risk not worth taking. Shewould reserve the use of hormone therapy for thosewomen in high-risk groups for whom lifestyle changesand alternative therapies are insufficient or unaccept-able.

In an excellent chapter entitled “Prevention and Risk:Understanding Research,” the reader is given a mini-course in analyzing the many types of studies with theirmethodologies, limitations, and biases. A major point isthat all of the studies thus far have presented onlycircumstantial evidence; it will not be until the year2008, with publication of the Women’s Health Initiative,that there will be a large major prospective randomizedcontrolled study dealing with effects of Premarin,Provera, calcium, vitamin D, and a low-fat diet on heartdisease, breast cancer and osteoporosis. Subsequentchapters dealing with the usual preventive indicationsrefer specifically to existing studies, pointing out theirstrengths and limitations.

The reference section reflects the authors’ meticulousresearch; nearly all of the references, including thosedealing with alternative therapies, come from respectedmedical journals. Many chapters include 40 or 50 suchreferences; citations from other books written for the laypublic are uncommon, but do include Susun Weed’shighly recommended book on herbal therapy for themenopausal years.

The solid theoretical background of the book covers indetail the biology of menopause, the physiology ofosteoporosis, and normal and abnormal coronary vascu-lar function. The book is directed to the educated layreader, but professionals will also appreciate the clarity

of the writing and will come away with new understand-ing. Illustrations enhance the text (eg, the artery as ahighway gradually clogged with debris thrown from cars,the bone as a house constantly being remodeled). Lovepresents a new view of osteoporosis, questioning theterm “disease” for low bone density, even when thereare no symptoms and no adverse consequences. Shesuggests that low bone density is a risk factor, andintermediate end-point, not synonymous with fracturerisk. This typifies her practice of questioning what sheconsiders to be overly simplistic interpretations of avail-able research.

The book is exceptional in its wealth of detailedpractical information. The author divides the approachesto managing menopause into three categories: lifestylechanges, alternative therapies, and drugs and surgery.Common menopausal symptoms are covered one byone, applying each of the three approaches. Laterchapters deal with general lifestyle changes, the aim ofwhich is prevention of the major menopause-relatedhealth problems. There is a complete and helpful chap-ter on hormone therapy, with positive guidelines forwomen who choose this option.

Two questionnaires are provided for readers to ratethemselves, both on distress due to menopausal symp-toms and on risk factors that might make them candi-dates for hormone therapy. A unique feature is Love’sgraphic illustrations of the numbers of women for whomhormone therapy would prevent hip fracture and heartattacks, and the additional numbers of women whowould get breast cancer from either estrogen alone orcombined estrogen-progestin therapy. Love has alsoanalyzed the data to produce tables comparing theefficacy of various approaches to the prevention ofosteoporosis and coronary vascular disease.

This reviewer would recommend Dr. Susan Love’sHormone Book to every midwife and midwifery student,and to their clients. It should, in fact, be required readingfor all professionals who care about the health of peri-menopausal women.

Normalizing the Breech Delivery. By Valerie El Halta,CPM and Rahima Baldwin Dancey, CPM. Produced byAmanda A. Smith, MFA. Video (VHS), 36 minutes.$59.95, $3.00 shipping and handling. P.O. Box 3675,Ann Arbor, MI 48106. 313-662-6857.

Reviewed by: Wendy L. Valhoff, MSN, CNM, Henry FordHealth Care Systems, Detroit, Michigan.

Normalizing the Breech Delivery is advertised as atraining video for birth attendants, regardless of whetherthey intend to perform breech deliveries. It is alsointended as an educational tool for clients. The video wasproduced and narrated by Valerie El Halta and RahimaBaldwin Dancey, Certified Professional Midwives

332 Journal of Nurse-Midwifery • Vol. 44, No. 3, May/June 1999