Tuesday was a busy day for the Oklahoma House Judiciary Committee. Legislators considered a measure to amend state firearms law, one pertaining to the collection and testing of sexual assault evidence, and another to modify state drug laws. Nestled within the committee’s agenda was Senate Bill 614, which would require abortion providers to counsel patients seeking medication abortion that the process can be reversed. Under the proposed law, a doctor who fails to provide this counsel would be committing a felony and potentially facing lengthy prison time.
The law is needed, Rep. Mark Lepak told the committee, because “medical science has developed a method for reversing the effects of a medication abortion and saving the life of an unborn child.”
The problem with Lepak’s statements — and the bill itself, which easily cleared the committee on a 13-3 vote — is that there actually is no sound science behind the claim that a medication abortion can be “reversed.” For this reason, medical associations like the American Congress of Obstetricians and Gynecologists have been unequivocal in their opposition to legislation like Oklahoma’s. “Claims regarding abortion ‘reversal’ treatment are not based on science and do not meet clinical standards,” the group wrote in a 2017 statement. Medical professionals also say the measure perverts the doctor-patient relationship by forcing physicians to peddle junk science — and reinforces the disproven stereotype that a large number of women who access abortion care later regret having done so.
There is no sound science behind the claim that a medication abortion can be reversed.
Priya Desai, a co-chair of Oklahoma Call for Reproductive Justice, says her group is adamantly opposed to legislation requiring doctors to provide “false information” to women. “It’s unacceptable to mandate lying to women about their healthcare,” she wrote in an email to The Intercept.
Medication abortion is typically a two-drug protocol available through the 10th week of pregnancy. The first pill, mifepristone, blocks progesterone, a hormone needed to maintain pregnancy. The second pill, misoprostol, taken roughly 48 hours later, forces the uterus to expel its contents. The idea behind so-called abortion pill reversal is that if a woman takes the mifepristone and then changes her mind about aborting the pregnancy before ingesting the misoprostol, she can take a large dose (or doses) of prescription progesterone to overwhelm the hormone blocker.
Theoretically, there is some “biologic plausibility” to the method, according to Dr. Daniel Grossman, the director of Advancing New Standards in Reproductive Health and a faculty member in the OB-GYN department at the University of California, San Francisco. The main problem is that it is unproven, and its safety and efficacy are unknown.
Abortion pill reversal is a protocol dreamed up by Dr. George Delgado, an anti-abortion physician in Southern California. It has spread through anti-choice circles primarily via Heartbeat International, a group that supports crisis pregnancy centers across the country.
Four states — Arkansas, Idaho, South Dakota, and Utah — currently have abortion pill reversal measures on the books. Seven additional states are currently considering bills similar to Oklahoma’s, which will almost certainly become law during the current legislative session.
Grossman first heard about the concept of using progesterone to “reverse” a medication abortion back in 2015, when Arizona’s efforts to force doctors to counsel their patients about it made headlines. “Nobody had heard of this before,” he recalled about asking other experts in abortion care. “I just thought, ‘This is pretty crazy.’”
He began going through research journals and found a case study, written by Delgado, involving seven women who’d been given progesterone to interrupt a medication abortion. Of the six women who participated in the study through its completion, four continued their pregnancies after taking progesterone. Delgado saw this as proof of the feasibility of his new method.
But Grossman and his colleagues — including Kari White, a professor in the School of Public Health at the University of Alabama at Birmingham — decided to interrogate Delgado’s research. They found serious flaws besides the small sample size: There was no explanation of how or why the women were chosen; there were several different progesterone regimens used; there was no control group; and the research was not overseen by an Institutional Review Board or ethics review committee. Ultimately, Grossman and White determined that there was “no evidence that the treatment they were describing was likely to be better than doing nothing,” White said. In other words, if a woman were to change her mind after taking the mifepristone, she could simply forgo the misoprostol and would be equally likely to continue the pregnancy.
Arizona couldn’t find a credible expert to testify that the protocol had any scientific underpinning.
Nonetheless, the bills proliferated — with mixed results. The Arizona law was ultimately repealed after a successful lawsuit. Although the state intended to defend the measure, it couldn’t find a credible expert to testify that the protocol had any scientific underpinning. In 2017, Colorado lawmakers rejected a similar measure, even though Delgado testified that reversal “is safe and effective.” He told a legislative committee, “Women who change their minds after taking mifepristone deserve the right to have a second chance at choice.” (Lepak used this same line on Tuesday to defend the Oklahoma bill against pushback by another member of the Judiciary Committee.)
Lawmakers in Louisiana, a state with some of the most restrictive abortion laws in the country, called on the state health department to review the science behind reversal, as a first step toward passing their own law in 2016. That effort failed after a panel of medical professionals came to the unanimous conclusion that “there is neither sufficient evidence nor a scientific basis to conclude that the effects of an abortion induced with drugs or chemicals can be reversed.”
In 2018, Delgado published a second case series with a far larger sample size and again arrived at the conclusion that his reversal method worked. But again, Grossman and White found serious flaws with the research: There were no clear protections for the women involved; some women were dropped from the study in a way that inflated its alleged success rate; and, again, there were a number of different regimens used.
“[Delgado’s studies] have not been done under the supervision of an IRB or an ethical review board. It’s really unclear if patients have been given adequate informed consent, and the reports are just incomplete,” Grossman said. “It’s really poorly done research.” Grossman and White again concluded that the evidence suggested a pregnancy was just as likely to continue if the woman took nothing after the mifepristone.
Delgado did not respond to The Intercept’s requests for comment.
For nearly a decade, Dr. Stephanie Ho has been providing abortion care in Arkansas, a state where lawmakers have worked steadily to curb abortion access under the pretense of “protecting” women. They’ve tried to ban medication abortion altogether and have devised informed consent materials that are medically inaccurate — including requiring doctors to counsel patients of the possibility of reversing medication abortion, a measure passed in 2015. “Basically, they’re using my mouth to lie to patients because they can’t do that themselves,” Ho told The Intercept.
The requirement is a dangerous intrusion on the doctor-patient relationship, she argues. After giving patients the inaccurate information the state forces her to provide, she then backs up and tells them what is accurate. It has confused and infuriated a number of her patients, who have asked why the state makes her lie to them. “That’s a really hard conversation to have,” Ho said.
She penned an explanatory letter to provide to every patient in this situation. “By inserting themselves into our conversation [state lawmakers] have violated our first amendment rights to free speech and have intruded into the time-honored doctor-patient relationship that we share at this critical time in your life,” reads the letter. “It is, however, the current state law in Arkansas.”
This session, lawmakers have tried to add to their abortion reversal law by proposing that patients also be given notice that if they want additional information, they should search the internet for “abortion pill reversal.” The suggestion exasperates Ho. “It’s going back to ‘don’t trust your doctor, look it up on the internet,’” she said. “And we all know that when we look at things on the internet and scare ourselves silly, that’s when we go to a doctor to get good evidence — not the other way around.”
It also appears that some lawmakers don’t even understand the theory that they require doctors to peddle. Arkansas state Sen. Missy Irvin recently told colleagues that the notice requirement would help a woman find a doctor who could “give her the shot of estrogen” needed to continue her pregnancy.
“It’s very clear that even the sponsors of the bill have no idea what this is.”
“It’s very clear that even the sponsors of the bill have no idea what this is, what its implications are, and how this can affect care,” Ho said. “I mean, they have absolutely no clue.”
Grossman is also troubled by lawmakers’ embrace of an unproven treatment that “steers patients into participating in an unmonitored research project,” he said. “That’s not how things work in medicine. We actually have to test experimental protocols and do it in a controlled way and get real data about safety and effectiveness.” It’s one thing if a “fringe group” is recommending something, he said, “but it’s another thing when it gets incorporated into legislation.”
Dr. Mae Winchester, an OB-GYN who testified on behalf of the American Congress of Obstetricians and Gynecologists against a reversal bill pending in the Kansas legislature, said that incorporating junk science into law is unethical. And so far, attempts to amend the Kansas bill to require that women also be told about ACOG’s position on reversal have failed.
“The most important thing a physician can do for their patients is to be honest about diagnosis, about treatment options — and this just completely destroys it,” Winchester said. She agrees that Delgado’s conclusions are flawed and finds it notable that his most recent research has not been published in a medical journal. Instead, it was published in Issues in Law and Medicine, a publication known for supporting anti-abortion and anti-vaccination rhetoric. (The publication did not respond to an emailed request for comment.) “It’s just false advertising,” Winchester said of Delgado’s work,“and these politicians are eating it up.”
Grossman and Ho are also concerned that pushing a false narrative around abortion reversal reinforces the notion that women choosing abortion are often uncertain or likely to regret their choice. Indeed, Lepak made that precise argument while urging his colleagues to vote in favor of the Oklahoma bill. “This is a pretty simple bill: It is possible to reverse an abortion with this procedure. We’re giving the woman a second chance,” he said. And that’s necessary, in his estimation, because there are “ministries” in the state that counsel women who regret their abortions. “The numbers are growing,” he said. “I don’t have specifics, but the fact that so many ministries exist out there for that reason, to me, is maybe the most powerful argument for allowing this bill to go forward and become law in Oklahoma.”
In fact, the opposite is true: Research reveals that women have very high confidence in their decision-making when it comes to abortion, remain confident in their choice, and have less anxiety and depression than women who were initially denied abortion care and had to seek it elsewhere or carry the pregnancy to term. Moreover, data shows that between 2000 and 2012, just 0.004 percent of women who took mifepristone subsequently decided to continue their pregnancy. Since 2000, medication abortion has been used by more than 2.75 million U.S. women.
“The anti-choice movement has focused on these bills around abortion reversal and put forward this notion that women really regret their decision,” Grossman said. “That’s not what the evidence shows.”