The report by Gissler et al.1 provides a valuable account of this issue. However, the data for the European Union (EU) imply a very disturbing East–West divide in terms of abortion rates despite much less significant differences in abortion legislation. Such a divide would need further analysis.
Liberalisation of abortion legislation in Eastern Europe was mostly taking place in the 1950s: Czechoslovakia (1950), Yugoslavia (1952), Hungary (1953), the Soviet Union (1955; partly even in 1919), Bulgaria (1956), Poland (1956; de-liberalised 1993) and Romania (1957; banned 1966–86). This happened mostly as a top–down political process by the then communist regimes, and was frequently seen as the most convenient method of fertility regulation.2 On the other hand, the legislation changes in Western Europe were mostly taking place two to three decades later, not to regulate fertility, but mainly to prevent unsafe abortions. In contrast to Western Europe, the official abortion rates in the East were extremely high after the change of legislation (up to few hundred abortions per 1000 women aged 15–44 years per year), which reflected systematic misuse of abortion as a method of fertility regulation.2
Despite democratisation and the improved economic situation in most of the Eastern European countries from the late 1980s, significant differences in abortion rates and in proportion of unsafe abortions still exist in comparison to Western Europe. According to the report by Gissler et al.1 all the EU member states with abortion rates over 20 were from the East (Bulgaria, Estonia, Romania), their abortion rates being up to four times higher than that of Germany. This phenomenon was recently shown also by Sedgh et al.3 The Eastern European countries (including those in the EU) had considerably higher abortion rates in comparison to other European countries (43 versus 12–18 per 1000 women aged 15–44 in 2008). The majority of Europe’s unsafe abortions took place in Eastern Europe. However, the legislation in Eastern Europe mostly contains a comparable degree of restrictions or fewer restrictions compared with legislation in Western Europe, where more countries with abortion on demand require pre-abortion counselling and/or a reflection period (e.g. Germany, France, Belgium) or allow abortion on demand only in practice but not formally (e.g. Spain, Finland).1 For the Eastern European EU member states (with the exception of Poland), it could be claimed that abortion is as safe and available as in other EU member states, but on the whole almost twice as prevalent.1 Besides the historical reasons, a lower prevalence of contraceptive use could be another important factor (but this is not clear from the latest United Nations figures).
All agree that that a strategy is needed to cut the number of all abortions—safe and unsafe, legal and illegal.4 The European East–West divide has not narrowed enough, despite some positive trends, mostly before 2003.1,3 More deliberation and efforts—especially better education—are needed in Eastern Europe to make abortions rarer and safer.