Portal de Periódicos da CAPES

The millennial mark

2001; Elsevier BV; Volume: 185; Issue: 2 Linguagem: Inglês

10.1067/mob.2001.116734

1097-6868

John Johnson,

Maternal and Neonatal Healthcare

Good afternoon, members and guests. I should begin by telling you, it is not easy to select a subject to discuss with this very learned and experienced audience. It must always be a challenge. I began where I'm sure many past presidents have begun. That is with a review of past presidential addresses. I was impressed to see how many were motivational in type: identifying goals for the future or emphasizing medical disorders that require special attention; citing needed improvements in clinical care; or proposing corrections in practice policy. All were important and inspirational topics to share with this organization. However, some of these addresses might be viewed as “preaching to the choir.” Clearly, you people have been elected to this organization primarily because of your recognized professional skills and your commitment to excellence in medical care. You are already “doing everything right.” But you're also community leaders, and it certainly does no harm to emphasize those aspects of our profession that need changing. However, today I plan to take a slightly different tact. The legendary big league baseball pitcher Satchel Paige once said, “Don't look back. Something might be gaining on you.”1Emily Morison Beck Bartlett's familiar quotations by John Bartlett.in: 14th ed. Little, Brown and Company, Boston1968: 1048Google Scholar In general, I would agree with Satchel Paige, that there's little to be gained by dwelling on the past. But it's instructional to reflect and to see where we've been. It's helpful to get feedback and to make an assessment about whether our efforts are being well expended. The end of a millennium would seem to be an excellent time to reflect on the past and to measure our progress. During the next 40 minutes, I would like for you to join with me in assessing what's transpired and what we've accomplished during the last millennium. It seems appropriate to begin this review by enumerating some of the remarkable advances that have taken place in medicine over the past 1000 years. I favor the list offered by the editors of the New England Journal of Medicine (Table).Tabled 1Table. The second millenniumElucidation of human anatomy and physiologyDiscovery of cells and their substructureElucidation of the chemistry of lifeApplication of statistics to medicineDevelopment of anesthesiaDiscovery of the relation of microbes to diseaseElucidation of inheritance and geneticsKnowledge of the immune systemDevelopment of body imagingDiscovery of antimicrobial agentsDevelopment of molecular pharmacotherapyAdapted from Looking back on the millennium in medicine. N Engl J Med 2000;342:42-9. Open table in a new tab These are cited in chronological order and are not necessarily in order of greatest accomplishment.2N Engl J Med. 2000; 342: 42-49Crossref PubMed Scopus (112) Google Scholar Adapted from Looking back on the millennium in medicine. N Engl J Med 2000;342:42-9. Interestingly, few of these advances were initiated before the Renaissance. None was an isolated event or discovery. Each was a series of notable steps that eventually led to a critical knowledge base in a given area. Apparently, this is the usual way in which medical information evolves.2N Engl J Med. 2000; 342: 42-49Crossref PubMed Scopus (112) Google Scholar These 11 advances in medical science were responsible for remarkable accomplishments in clinical medicine. I want to review some of the consequences of these developments with you next. Of course there was no United States at the beginning of the last millennium. So it is not possible to accurately document progress over the entire 1000 years. However, there are excellent national data to describe or mark the progression in health care at the end of the last millennium. And contrasting these data with data available from decades or even a century ago does give us an indication of the rate of change in this country at the end of the last 1000 years. Let's examine how “the choir has performed.” The general health and welfare of the population of this country is excellent and continues to improve. In the year 1900, the life expectancy for women was 46 years of age and for men 45 years of age. In Fig 1, life expectancy is depicted by year for white women, black women, white men, and black men.Life expectancy increased to a record high of 76.7 years in 1998.3Murphy SL Deaths: final data for 1998.National Vital Statistics Reports no 11. vol 48. National Center for Health Statistics, Hyattsville, Md2000Google Scholar This is the highest value ever recorded in the United States and a 69% increase since 1900. There are racial and sex-related disparities as shown, but the rate of improvement is close to the same for all 4 groups. Deaths because of cardiovascular disease, including coronary artery disease, and stroke are declining and have done so for at least 25 years.4Centers for Disease Control and Prevention Decline in deaths from heart disease and stroke united states, 1900-1999.MMWR. 1999; 48: 649-652PubMed Google Scholar The average mortality rate because of cancer is no longer rising but has leveled off now and appears to be on the cusp of declining for the first time since it has been recorded. Even deaths because of homicide and Alzheimer's disease are down.3Murphy SL Deaths: final data for 1998.National Vital Statistics Reports no 11. vol 48. National Center for Health Statistics, Hyattsville, Md2000Google Scholar Worldwide infection with the human immunodeficiency virus (HIV) that often may culminate in the acquired immunodeficiency syndrome (AIDS) continues to be a deadly pandemic affecting 36 million people worldwide. Of the estimated 5.3 million new infections in 1999, 4 million occurred in sub-Sahara Africa where 90% of infections are due to heterosexual contact. In some African countries HIV/AIDS infection has the potential for increasing child death 3-fold and reducing life expectancy to 20 years. We are extremely fortunate in the United States to be able to provide multiple, potent antiretroviral agents that can reduce the progression of HIV infection to AIDS. The number of deaths caused by AIDS infection has decreased by more than 70% in the last 5 years in this country.3Murphy SL Deaths: final data for 1998.National Vital Statistics Reports no 11. vol 48. National Center for Health Statistics, Hyattsville, Md2000Google Scholar (But the number of new HIV infections occurring annually remains constant at about 40,000.) As primary care physicians specializing in women's health care, our profession is participating in these improvements in general health and committed to their continuance. Now, let's address some of the outcomes more specific to our specialty. The maternal and the infant mortality rates are recognized as important measures of societies' ability to organize and deliver effective medical care to its most vulnerable individuals. These rates have been counted and compared on an international basis, at least since the beginning of the last century. They serve as sentinel markers to those concerned with health care. On a worldwide basis, we do not do well with the care of pregnant women. An estimated 600,000 maternal deaths occur annually. Every minute, somewhere in the world, a woman dies of complications from pregnancy and childbirth. In developing countries, pregnancy imposes a tremendous risk for the woman and her child. This was brought home very graphically to me in Nigeria, when I was at the University of Ibadan years ago. The just-delivered Yoruba mothers had a standard greeting for each other, which translated to “congratulations that you're still alive.” Those women fully understood the hazards of being pregnant. In the United States, we experienced a similar loss rate in 1900 when 1 out of every 100 pregnant women (1%) died. But we have made impressive improvement since then. The maternal mortality rate improved to 6/1000 in 1935 and to 8/100,000 in 1982.5Centers for Disease Control and Prevention Healthier mothers and babies.MMWR. 1999; 48: 849-857PubMed Google Scholar Fig 2 provides a better indication of the change in mortality rate in the United States over time.Years are plotted on the abscissa and deaths per 100,000 live births on the ordinate. The 0.5% to 1% maternal mortality rate seen in the early years of the twentieth century was due to the fact that most deliveries were performed by poorly skilled practitioners, who knew little about aseptic technique. Sepsis accounted for 40% of the deaths, one half after vaginal delivery and one half after illegally induced abortion. The remaining deaths were due to hemorrhage and high blood pressure.5Centers for Disease Control and Prevention Healthier mothers and babies.MMWR. 1999; 48: 849-857PubMed Google Scholar The apparent increase in maternal mortality rates recorded around 1920 is ascribed to the improved reporting of maternal deaths. The decreased deaths noted during the 1930s and 1940s are attributed to the establishment of state mortality review committees who instituted effective practice guidelines. Simultaneously, there was a shift from home to hospital deliveries. In the 1940s the proportion of infants born in hospitals increased from 55% to 90%. During the 1950s and 1960s medical advances, including antibiotics, oxytocin to induce labor, safe blood transfusion, and better management of hypertensive conditions brought about further declines. And the legalization of induced abortion early in the 1960s eliminated deaths from illegal septic abortions. The maternal mortality rate of 7.2 per 100,000 in 1996 represents a 99% decrease since 1900.5Centers for Disease Control and Prevention Healthier mothers and babies.MMWR. 1999; 48: 849-857PubMed Google Scholar In recent decades in the United States, the mortality rate associated with term pregnancy has been 10-fold higher than the mortality rate associated with induced abortion or contraception. The mortality rate of women in motor vehicle accidents has been higher at 11 per 100,000. In the United States today, driving a motor vehicle is more dangerous for women than pregnancy. The sharp decline in maternal mortality rate observed in the United States, especially with its diverse population, is a clear tribute to better access to care and to modern medicine. Another important measure of a society's organization and humanness toward its members is its infant mortality rate. This has been monitored in the United States since 1900 and is recorded in most other developed countries as well. In the early 1900s, for every 1000 live births, approximately 100 infants died before the age of 1 year, which constitutes a 10% infant mortality rate. In some U.S. cities in the early 1900s, 30% of infants died before reaching their first birthday. Efforts to reduce this terrible mortality rate were focused on improving environmental and living conditions. The establishment of sewage disposal and of safe drinking water was important in reducing infant mortality rates during these years. Milk pasteurization, first introduced in Chicago in 1908, was key to eliminating milk-borne diseases.5Centers for Disease Control and Prevention Healthier mothers and babies.MMWR. 1999; 48: 849-857PubMed Google Scholar For the first 3 decades of the twentieth century, public health and social welfare officials and physicians (pediatricians and obstetricians) collaborated to combat infant death. The problem was addressed in a public health approach that included infant, mother, and prenatal care programs. The advent of antimicrobial agents, the development of fluid and electrolyte replacement, and safe blood transfusions accelerated the decline in infant mortality rates during the 1930s and 1940s. During the late 1960s Medicaid and other federal programs made prenatal care and hospital deliveries more accessible, and infant mortality rates continued to decline. During the 1970s, thanks to technological advances in neonatal medicine and the regionalization of perinatal services, neonatal mortality rates continued to decline. The increasing use of maternal steroids and the availability of artificial pulmonary surfactant accounted for added substantial decreases. Subsequent improvements in infant mortality rates were due primarily to decreases in sudden infant death syndrome.5Centers for Disease Control and Prevention Healthier mothers and babies.MMWR. 1999; 48: 849-857PubMed Google Scholar The infant mortality rate of today represents a 90% decrease from that experienced at the beginning of the twentieth century.5Centers for Disease Control and Prevention Healthier mothers and babies.MMWR. 1999; 48: 849-857PubMed Google Scholar These remarkable reductions over the last century are impressive accomplishments for our nation and for our health care system. And the rate continues to march downward. One of the major obstetric and social problems in this country is the high incidence of teenage pregnancy, so well discussed by Dr Bill Le Hew in his fifty-fourth presidential address to this organization.6Le Hew WL Teenage pregnancy prevention: the vital importance of the medical community's involvement.Am J Obstet Gynecol. 1992; 162: 299-302Abstract Full Text PDF Scopus (3) Google Scholar The United States has one of the highest frequencies of teenage pregnancy recorded in the world. Our rates are 4 times higher than that of Germany, 6 times higher than that of France, and 8 times higher than that of The Netherlands. According to 1997 data, more than 480,000 babies were born to U.S. women age 15 to 19 years. Teenage pregnancies are associated with increases in rates of maternal death and morbidity, premature delivery, stillbirth, infant death, and child abuse.7The American College of Obstetricians and Gynecologists Adolescent pregnancy facts. The American College of Obstetrics and Gynecology, Washington, DC2000Google Scholar The frequency of teenage pregnancy was first recorded for this country in 1960. The rate at that time was higher than any recorded since. There were substantial declines over the next 25 years to 1986. Increasing rates were noted again in 1987, but this trend peaked in 1991, with rates comparable to those reported in 1971.8Ventura SJ Mathews MS Curtin SC Decline in teenage birth rates 1991-1998: update of national and state trends.National Vital Statistic Reports no. 26. vol 47. National Center for Health Statistics, Hyattsville, Md1999Google Scholar Important declines have occurred consistently since 1992. The latest figures available of 51.1 live birth/1000 teenagers (1998) are very close to the 1986 record low of 50.2 and represent a 57% decline since 1960.8Ventura SJ Mathews MS Curtin SC Decline in teenage birth rates 1991-1998: update of national and state trends.National Vital Statistic Reports no. 26. vol 47. National Center for Health Statistics, Hyattsville, Md1999Google Scholar, 9Ventura SJ Mosher MD Curtin SC Abma JC Henshaw S Highlights in trends in pregnancies and pregnancy rates by outcome: estimates for the United States, 1976-1996.National Vital Statistics Reports no 29. vol 27. National Center for Health Statistics, Hyattsville, Md1999Google Scholar Teenage pregnancy rates tend to be higher in Hispanic and black groups and are associated with differences in family stability and economic opportunity. But in recent years, the greatest declines have been seen in black teenagers, in whom the 1998 rate was at an all-time low.8Ventura SJ Mathews MS Curtin SC Decline in teenage birth rates 1991-1998: update of national and state trends.National Vital Statistic Reports no. 26. vol 47. National Center for Health Statistics, Hyattsville, Md1999Google Scholar, 9Ventura SJ Mosher MD Curtin SC Abma JC Henshaw S Highlights in trends in pregnancies and pregnancy rates by outcome: estimates for the United States, 1976-1996.National Vital Statistics Reports no 29. vol 27. National Center for Health Statistics, Hyattsville, Md1999Google Scholar The South Atlantic states have done well in reducing teenage pregnancy rates, with Virginia and Florida leading. North Carolina and South Carolina are in close pursuit.8Ventura SJ Mathews MS Curtin SC Decline in teenage birth rates 1991-1998: update of national and state trends.National Vital Statistic Reports no. 26. vol 47. National Center for Health Statistics, Hyattsville, Md1999Google Scholar It is not possible to definitely identify the causes of these reductions in the pregnancy rate among teenagers. But community and school educational programs, as well as more effective means of contraception, have assisted significantly. In addition to reductions in the pregnancy rate and the live birth rate, there has also been a large reduction in the induced abortion rate among teenagers. The abortion rate fell 33% from 1988 to 1996.9Ventura SJ Mosher MD Curtin SC Abma JC Henshaw S Highlights in trends in pregnancies and pregnancy rates by outcome: estimates for the United States, 1976-1996.National Vital Statistics Reports no 29. vol 27. National Center for Health Statistics, Hyattsville, Md1999Google Scholar Louise Brown, the product of the first in vitro fertilization procedure turned 21 years of age last year. The total annual number of in vitro fertilization procedure cycles is now approaching 500,000 worldwide, with an estimated average pregnancy rate of 20% per embryo transfer. In vitro fertilization procedure success rates as high as 50% per cycle are reported by some centers.10Fauser BCJM te Velde ER The brave new world of making babies.The Lancet. 1999; 354: 40PubMed Google Scholar The Women's Center at the University of Florida reports success rates of approximately 45% per cycle for women less than 35 years of age; 25% per cycle for women aged 36 to 40 years; and approximately 10% to 15% per cycle for those over age 40 years.11Williams RS Infertility care in the new millennium.Alachua County Medical Society House Calls. 2000; Sept-Oct: 12-13Google Scholar Since the early 80s, assisted reproductive technologies have increased in number and in variety. The number of patients using assisted reproductive procedures has increased to an estimated 35,000 to 40,000 in 1997; 10 times the frequency recorded for 1985. Although in vitro fertilization procedure is now a conventional method of treatment, further developments include preimplantation genetic diagnosis; intracytoplasmic sperm injection; surrogate motherhood; oocyte, sperm, and embryo donation; cryopreservation of human ovarian tissue with subsequent maturation of oocytes in culture (so-called fertility insurance) ; and embryo cloning. These developments have created entirely new possibilities for future procreation in addition to highly complex questions about ethical, legal, psychosocial, and medical boundaries. These will be solved in time by our society, the courts, and the medical profession.10Fauser BCJM te Velde ER The brave new world of making babies.The Lancet. 1999; 354: 40PubMed Google Scholar Infectious disease complications have always been a major cause of obstetric complications. An infectious disease problem currently being addressed is that of perinatal group B streptococcal infection. It became evident as early as the 1970s that group B streptococcal infection was a leading cause of neonatal death and morbidity in the United States. It is estimated that approximately 6100 cases occurred annually and about 300 neonates actually succumbed to the infection. The surviving infants are known to have developmental disabilities, including hearing loss, vision loss, and mental retardation. Maternal infection can also complicate this disease state.12Schrag SJ Zywicki S Farley MM Reingold AL Harrison LH Lefkowitz LB et al.Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis.N Engl J Med. 2000; 342: 15-20Crossref PubMed Scopus (867) Google Scholar Although clinical trials in the 1980s demonstrated that prophylactic antibiotics during labor could reduce the incidence of neonatal infection, consensus guidelines for the prevention of perinatal streptococcal infections did not emerge until 1997. These guidelines recommended the use of a risk-based or screening-based approach to identify patients for intrapartum prophylaxis with penicillin. A concurrent decrease in the rate of infection was noted.12Schrag SJ Zywicki S Farley MM Reingold AL Harrison LH Lefkowitz LB et al.Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis.N Engl J Med. 2000; 342: 15-20Crossref PubMed Scopus (867) Google Scholar A number of studies have monitored the effect of intrapartum penicillin prophylaxis for group B streptococcus. Most of these have shown a major reduction in the frequency of group B streptococcal infection, with the incidence being reduced by 65% to 88%. The higher improvement rates have been noted in black infants. Extrapolation of this surveillance data to national estimates suggests that the use of prophylactic antibiotics has reduced the number of infected newborns from 6100 to 2200 and the deaths from 300 to 100 annually. Reductions in morbidity rates for the mother have also been reported.12Schrag SJ Zywicki S Farley MM Reingold AL Harrison LH Lefkowitz LB et al.Group B streptococcal disease in the era of intrapartum antibiotic prophylaxis.N Engl J Med. 2000; 342: 15-20Crossref PubMed Scopus (867) Google Scholar A particularly unfortunate and dreaded complication of HIV infection is vertical transmission to the innocent child during passage through the birth canal. Of the 160,000 females infected with HIV in the United States, most are of reproductive age, and 5000 to 6000 are expected to become pregnant annually. An estimated 1500 newborns could be infected during delivery each year.13Scott JR Victories won; victories deferred.OBG Management. 1999; Oct: 48-68Google Scholar The landmark results of study, a multi-institutional collaborative project regarding the efficiency of zidovudine treatment of HIV-infected pregnant women was first published in 1994.14Connor EM Sperling RS Gelbert R Kiselev P Scott W O'Sullivan MJ et al.Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment.N Engl J Med. 1994; 331: 1173-1180Crossref PubMed Scopus (3386) Google Scholar This study demonstrated the ability of zidovudine to reduce the risk of vertical transmission to the fetus. It is now standard care in this country to treat all pregnant women infected with HIV with antiretroviral drugs during the course of the pregnancy and delivery and to treat the neonate immediately after delivery. There was a peak rate of infection with HIV in newborns of 8 to 9 per 100,000 in the early 1990s. With zidovudine prophylaxis in the newborn, the infection rate has declined to 3 per 100,000 in 1996.13Scott JR Victories won; victories deferred.OBG Management. 1999; Oct: 48-68Google Scholar This represents a 68% decline in the expected rate of infection and is one of the most important infectious disease triumphs in our profession in decades. Cancer of the cervix and breast remain major ongoing challenges for the obstetrician and gynecologist. In spite of the fact that the mortality rate for cancer of the cervix has decreased from 21/100,000 women in 1950 to 2/100,000 in 1996 (90% reduction), cervical cancer still ranks third among all gynecologic cancers as a cause of patient death. The American Cancer Society predicted that for the year 2000, approximately 12,800 new cases of invasive cancer would be diagnosed, and 4600 cervical cancer–related deaths would occur in the United States.15Centers for Disease Control and Prevention CDC recommendations regarding selected conditions affecting women's health.MMWR. 2000; 492: 37-55Google Scholar Although the etiology of cancer of the cervix is unknown, high risk factors have been well established. They include human papillomavirus infections; early age of first intercourse; multiple male sexual partners; history of sexually transmitted diseases; smoking; and lower socio-economic status. Well known to all of you, the cervical cytology test developed by Drs Papanicolaou and Traut in 1943 (the Pap test) has proven to be one of the more effective cancer screening tests available. In the United States, approximately 50 million Pap tests are performed annually. It enables clinicians to detect cancer and precancerous cervical intraepithelial neoplasia. The latter can be eradicated by treatment, thereby preventing cervical cancer. Fig 3 illustrates the incidence and death rate for cancer of the cervix per 100,000 women.Use of the Pap smear is primarily responsible for the continued decline in cancer of the cervix observed since the 1950s. If further declines are to be achieved, however, the Pap test screening frequency among the women of this country must increase substantially above current estimates of 75% to 80%.15Centers for Disease Control and Prevention CDC recommendations regarding selected conditions affecting women's health.MMWR. 2000; 492: 37-55Google Scholar One of the gravest threats to women living in the United States today is breast cancer. It is the most commonly diagnosed cancer in women and remains second only to lung cancer as a cause of cancer-related death. In this country 182,800 new cases and 41,200 deaths were predicted for the year 2000.15Centers for Disease Control and Prevention CDC recommendations regarding selected conditions affecting women's health.MMWR. 2000; 492: 37-55Google Scholar The risk of breast cancer increases with advancing age. The incidence is 1 per 1000 in the 30 to 40 age group, and 3 per 1000 among the 50 to 60 age group. Among women reaching the age of 90 years and above, the incidence is 125/1000 or 1 of 8. Current textbooks state that the mortality rate has not changed appreciably since 1930. But recent data indicate that changes are occurring. Although the cause is unknown, a number of risk factors have been determined. As we all know, these include advanced age, a positive family history, certain benign breast diseases, early age at menarche, late age at menopause, exposure to ionizing radiation, obesity, white race, nulliparity, late age of first birth, and higher socioeconomic status. Less clearly established factors include use of oral contraceptive medications, estrogen replacement therapy, alcohol consumption, and a history of not breast feeding.15Centers for Disease Control and Prevention CDC recommendations regarding selected conditions affecting women's health.MMWR. 2000; 492: 37-55Google Scholar Studies of immigrants to the United States suggest that environmental factors are much more important than genetic factors. For example, the rate of breast cancer among first-generation Japanese American women is only slightly different from the low rate among their mothers still in Japan. But the rate among the daughters of first-generation Japanese American women is considerably higher. These environmental factors have not been identified. As a strategy to reduce the deaths related to breast cancer, prevention does not lend itself to easy application. Most established risk factors are neither environmental nor behavioral. Early detection and treatment is the most efficient strategy. Mammography is the most effective means of detecting breast cancer at its earliest and most treatable stage. It has a sensitivity of 75% to 94%, which is higher then values noted for clinical physical examination or even patient self-examination. Mammography can detect cancer too small to be palpated by physical examination. At the same time, a negative examination result tends to exclude the presence of breast cancer, as evidenced by a specificity of 83% to 98%. There is some debate about the cost-effectiveness of mammography from age 40 to 50 years, but the most recent advisory panels do recommend screening tests every 1 to 2 years after age 40 years and annual tests after age 50 years.15Centers for Disease Control and Prevention CDC recommendations regarding selected conditions affecting women's health.MMWR. 2000; 492: 37-55Google Scholar It is important to remind our patients that, as efficient as mammography may be, it can still miss carcinoma of the breast. Screening programs must include serial physical examinations. Data from the National Cancer Institute surveillance program indicates that in the United States the incidence of breast cancer increased 25% from 1973 to 1996. However, the impressive corollary is that the death rate of invasive breast cancer has not paralleled this increase in incidence. Indeed there has been about a 5% decrease in the mortality rate from 1992 to 1996. This is attributed to earlier diagnosis and more effective treatment with drugs such as tamoxifen.15Centers for Disease Control and Prevention CDC recommendations regarding selected conditions affecting women's health.MMWR. 2000; 492: 37-55Google Scholar Because of the time delay in retrieving national results, it has only become evident very recently that a major reduction in the breast cancer mortality rate is occurring in both the United States and the United Kingdom. The data from Peto et al16Peto R Boreham J Clarke M Davies C Beral V UK and USA breast cancer deaths down 25% in year 2000 at ages 20-69 years.Lancet. 2000; 355: 1822Abstract Full Text Full Text PDF PubMed Scopus (556) Google Scholar from the cancer epidemologic unit at Oxford are shown in Fig 4.16Peto R Boreham J Clarke M Davies C Beral V UK and USA breast cancer deaths down 25% in year 2000 at ages 20-69 years.Lancet. 2000; 355: 1822Abstract Full Text Full Text PDF PubMed Scopus (556) Google ScholarThese data illustrate that the mortality rate of cancer of the breast has been decreasing in both the United States and the United Kingdom since the late 1980s. Indeed, extrapolating the most recent data from 1997, Peto et al16Peto R Boreham J Clarke M Davies C Beral V UK and USA breast cancer deaths down 25% in year 2000 at ages 20-69 years.Lancet. 2000; 355: 1822Abstract Full Text Full Text PDF PubMed Scopus (556) Google Scholar predicts that in the United States the year 2000 will be characterized by a 20% drop in the mortality rate or 10,000 fewer deaths than predicted earlier. A 30% decrease is estimated to have occurred in the United Kingdom for the year 2000. The suddenness of these reductions in breast cancer mortality rates suggests that the improvements are due mostly to changes in diagnosis and treatment. This is the first time that changes in treatment of any type of cancer have produced such a rapid fall in national mortality rates. These reported trends are certainly encouraging news that seem to document the efficacy of breast cancer screening. Better patient compliance in screening could yield further improvements. Surveillance sampling suggests that only 70% of women participate in regular screening programs. A compliance rate of 100% could reduce mortality rates by another 19% to 30%.15Centers for Disease Control and Prevention CDC recommendations regarding selected conditions affecting women's health.MMWR. 2000; 492: 37-55Google Scholar In summary, we have reviewed the remarkable medical gains that mark the last millennium in this country. They include an increase in life expectancy, reduced maternal and infant mortality rates, decreased teenage pregnancy, improvements in infertility management, the prevention of newborn group B streptococcus and HIV infection, and reductions in cervical and breast cancer mortality. Although we have not discussed all the advances that have been made in the field of obstetrics and gynecology, these are certainly the main outcome variables about which we have good statistical records. I believe that if I were the preacher, I would conclude that toward the end of this last millennium, the choir has made very strong music! The anthems have been clear and loud!