It is widely agreed that one of the major achievements in women’s health in the last millennium has been the availability of safe and effective contraception. The ability of couples to regulate their fertility is a fundamental human right which unfortunately is often not recognized in all countries. It is for this reason that, once again, we are reviewing the challenges in fertility regulation, looking at new developments and assessing what is available in both industrialized societies and developing countries. Often in developing countries there is less governmental commitment to contraceptive services and certainly a far smaller budget despite the very great need.

In 1965, Professor Dugald Baird presented a paper which was published in the British Medical Journal and which outlined the important role of accessible fertility regulation . He emphasized the need for a ‘fifth freedom’ in addition to the four important freedoms outlined by the President of the USA, Franklin D Roosevelt. Professor Baird’s fifth freedom was freedom from unwanted and uncontrolled fertility. This was a landmark presentation and has been quoted and supported over the decades. His insights into the needs of women and his vision for the future were quite extraordinary some five decades ago. It is recognized that women will only be truly able to control their fertility if they are given the means and the support to use reliable contraception.

At present, there are some 222 million women worldwide with unmet contraceptive needs and this results in about 80 million unintended pregnancies per annum and 20 million unsafe abortions with the significant mortality and morbidity which results from these events. These figures have been published by the WHO and present an overview of what is available around the world for women who are trying to control their fertility.

Cleland’s review in this journal in 2009 assessed the historical development of contraceptive services around the world . In the Western world, most of the original contraceptive services were male orientated and utilized condoms or coitus interruptus. As new developments for fertility regulation have been put in place and safe methods of female contraception have become available, these services and technologies have been expanded to both the Western world and developing countries. Access to good fertility regulation and contraceptive services has varied around the world with some notable successes and some unfortunate failures.

The Millennium Development Goals (MDGs) were formulated following the Millennium Summit in 2000 and MDG 5 aimed at ‘Improving maternal health’. This MDG specifically dealt with reducing maternal mortality and morbidity from 1990 to 2005. For some inexplicable reason there was no inclusion of the need for reproductive health and contraceptive accessibility. After much lobbying by the International Planned Parenthood Federation (IPPF) and the United Nations Population Fund (UNFPA), among other organizations, in 2005 MDG 5b was included in the MDGs. This explicitly presents targets on reproductive health and these include contraceptive prevalence rates. Given the information we have about the lack of access to modern methods of contraception in developing countries, it is remarkable that this MDG was only added in 2007 and it certainly will not be achieved by 2015.

We are tempted to postulate that contraception perhaps remains the ‘stepchild’ of women’s health as it was not even considered when the MDGs were being formulated. New technologies have become available and have been expanded throughout the Western world and to some extent to developing countries too. Programmes for fertility regulation have varied around the world and financial considerations are central to the availability of new methods in under-resourced areas.

Darroch and Singh presented the trends in contraceptive need and use in developing countries in a Lancet article in 2012 . It is obvious that women wishing to avoid unintended pregnancy and who need effective contraception often do not have their requirements addressed within the services provided in their country. While the use of modern contraceptive methods has increased worldwide, there still remains a large proportion of women who would wish to control their fertility but who are not given access to suitable contraceptive options.

Numerous challenges in reproductive health and particularly fertility regulation still need to be addressed. It has been stated that a women ‘cannot die from a pregnancy she does not have’ and this obviously is a truism. The prevention of unintended pregnancy also impacts on perinatal and child mortality. There is general agreement that ‘contraception is maternal health’ and obviously we understand the rationale behind this statement. Often the needs of developing countries are not adequately recognized. The health budgets are small and costs of newer technologies such as the intrauterine system are perceived as unaffordable. In addition, the HIV pandemic which has particularly affected Africa has had an impact on contraceptive usage and at present we have concerns about possible increased transmission of HIV with the use of some progestogen-only contraceptive methods. These concerns still need to be comprehensively addressed.

The success of contraceptive endeavours in Africa was partially negated by the AIDS challenge. In the past, it was always agreed that women would use contraception if they had the assurance that their children would live to support them in later years. With HIV/AIDS, this has become a different challenge and many women increased their family size simply to deal with the anticipated death of their children from AIDS or the need to ‘replace’ children who had died from HIV/AIDS.

This edition of Best Practice and Research Clinical Obstetrics and Gynaecology concentrates on fertility regulation. We have tried to deal with current accepted methods of contraception, review controversial areas such as male contraception and then deal with special groups. It is hoped that the readers will find this publication helpful in their clinical practice.