Medication Abortion “Reversal” Laws: How Unsound Science Paved the Way for Dangerous Abortion Policy

Abstract

Objectives. To longitudinally examine the legal landscape of laws requiring abortion patients be informed about the possibility of medication abortion (MAB) “reversal” (in quotes as it does not refer to an evidence-based medical procedure).

Methods. We collected legal data on enacted state MAB-reversal laws across all 50 US states and Washington, DC, (collectively, states) from 2012 through 2021. We descriptively analyzed these laws to identify legal variation over time and geography, and conducted a content analysis to identify qualitative themes and patterns in MAB-reversal laws.

Results. As of 2021, 14 states (27%)—mostly in the midwestern and southern United States—have enacted MAB-reversal laws. States largely use explicit language to describe reversal, require patients receive information during preabortion counseling, require physicians or physicians' agents to inform patients, instruct patients to contact a health care provider or visit “abortion pill reversal” resources for more information, and require reversal information be posted on state-managed Web sites.

Conclusions. Reversal laws continue a dangerous precedent of using unsound science to justify laws regulating abortion access, intrude upon the patient‒provider relationship, and may negatively affect the emotional and physical health of patients seeking an MAB. (Am J Public Health. 2023;113(2):202–212. https://doi.org/10.2105/AJPH.2022.307140)

Medication abortion (MAB)—the use of medications to induce an abortion up to the first 10 to 11 weeks of pregnancy—has rapidly become a popular abortion care method over the past 2 decades. While abortions in the United States have largely decreased since 2000, MABs have continued to rise and currently constitute the majority of all abortions in the United States, accounting for 54% of all nonhospital abortions as of 2020.¹ In addition, MAB is highly effective and extraordinarily safe, with a less-than-1% risk of complications.¹ With its rise in popularity, MAB has become a frequent target for state legislatures seeking to restrict abortion access and provision. One such regulation is MAB “reversal” laws (“reversal” placed in quotations, as this term does not refer to an evidence-based medical procedure), which—like other biased abortion counseling laws—require that patients receive medically inaccurate information about the possibility of reversing a MAB.

Fewer than 0.005% of patients who use mifepristone choose to continue their pregnancy; the current clinical recommendation for such patients is watchful waiting and fetal monitoring.² MAB reversal is an experimental procedure involving the administration of a high dose of progesterone following the initial dose of mifepristone should a patient who is using MAB choose to continue their pregnancy. MAB reversal was initially described in a 2012 case series by Delgado and Davenport, which presented cases of 6 patients who received 200 milligrams of progesterone following mifepristone ingestion, 4 of whom carried pregnancies to term.³ Based on this 2012 case series, a 2017 article by Garratt and Turner detailed cases of 3 patients treated with progesterone following mifepristone ingestion, 2 of whom carried pregnancies to term.⁴ The following year, Delgado et al. published a second case series of 754 patients who underwent the experimental procedure, reporting an “overall rate of reversal of mifepristone [of] 48%.”⁵

Numerous ethical and scientific problems highlight the poor quality of these case series. The lack of evident oversight by an institutional review board or ethics committee and apparent failure to obtain patient consent demonstrate neglect of common ethical standards and study participant protection. Scientifically, the data produced by these studies are of a low standard because of the failure to employ standardized scientific protocols, lack of comparison group, artificial inflation of pregnancy completion rates by assessing pregnancy viability before reversal, and incomplete reporting of patient outcomes. Together, these studies fail to provide rigorous scientific evidence supporting MAB reversal.²

One randomized clinical trial attempted to evaluate safety and efficacy of MAB reversal⁶ but was ceased prematurely to protect participants because of 3 instances of severe hemorrhage requiring ambulance hospital transport. Study authors concluded that MAB reversal is “experimental and should be offered only in institutional review board-approved human clinical trials to ensure proper oversight.”^6(p164) Experts from the medical and public health communities have denounced MAB reversal as unsafe, unproven, and unethical.^6–10 However, MAB reversal swiftly gained the attention of state legislators, who have subsequently enacted legislation requiring MAB reversal information be included during the abortion process.

A summary by Bhatti et al. described state MAB-reversal legislation as of 2018, noting that legislators had introduced MAB-reversal bills in 9 states and successfully enacted laws in 3 of those states.⁹ Given the continued increase in antiabortion legislation—including MAB-reversal laws—since 2018, we collected data on state MAB-reversal laws through 2021 to provide an updated overview of the MAB-reversal legal landscape in the United States. We descriptively analyzed these laws to identify legal variation over time and geography and conducted a content analysis¹¹ of legal texts to identify themes and patterns in MAB-reversal laws.

METHODS

We collected data on MAB-reversal laws across all 50 states and Washington, DC, (collectively, states) from 2012 to 2021. We gathered state statutory laws requiring patients be told about MAB reversal during the abortion process, including via conversations with clinic providers or staff, physical signs, discharge materials, medication guides, or state-managed Web sites. We included laws currently in effect and temporarily enjoined pending litigation and tracked implementation from January 1, 2012, through December 31, 2021. We gathered full versions of legal text using Nexis Uni and validated our data using LawAtlas’s Medication Abortion Requirements data set.¹² We reported the number and percentage of states with enacted MAB-reversal laws for each year of the study period to examine their proliferation over the study period. To visualize these time trends, we created a map indicating the year in which each state enacted the first reversal law.

In addition, we conducted a content analysis of statutes,¹¹ identifying themes and patterns in how states prescribe MAB-reversal information be provided to patients. To conduct the content analysis, we first created a tentative set of coding categories based on a preliminary examination of the MAB-reversal legal data, which we refined following an in-depth review of the data. Codes examined the following domains: language used to describe reversal (i.e., explicit vs generic language); reference to supporting “scientific research”; when, how, and by whom patients are informed; what actions patients should take; penalties for providers or clinics; and requirements for information on state-managed Web sites. We then applied the refined codes to the data, ensuring objectivity and reliability through repeated coding of the laws by the coder. We then summarized coding findings (e.g., documenting the recurrence of themes present in the laws) and reported them in a systematic manner.

RESULTS

Table 1 displays a list of states with MAB-reversal laws, corresponding legal citation, legislation, enactment and effective dates, and current status of each law.

TABLE 1—

State Medication Abortion‒Reversal Laws by Legal Citation, Corresponding Legislation, Enactment and Effective Dates, and Current Law Status: United States, 2012–2021

State	Legal Citation	Corresponding Legislation	Enactment Date	Effective Date	Current Status
AZ	Ariz Rev Stat §36-2153	2015 Ariz SB 1318 2016 Ariz SB 1112	Mar 30, 2015 May 17, 2016	Jul 3, 2015 Aug 6, 2016	Effective
AR	Ark Code Ann §20-16-1703 Ark Code Ann §20-16-1704	2015 Ark HB 1578	Apr 6, 2015	Jul 22, 2015	Effective
ID	Idaho Code §18-609	2018 Idaho SB 1243	Mar 20, 2018	Jul 1, 2018	Effective
IN	Ind Code Ann §1-34-2-1	2021 Ind HEA 1577	Apr 29, 2021	Jul 1, 2021	Enjoined—preliminary injunction granted Jun 30, 2021
KY	Ky Rev Stat §311.725 Ky Rev Stat §311.774	2019 Ky SB 50	Mar 26, 2019	Jun 27, 2019	Effective
LA	La Rev Stat §40:1061.11.1	2021 La HB 578	Jun 19, 2021	Aug 1, 2021	Effective
MT	Mont Code Ann 50-20-707 Mont Code Ann 50-20-708	2021 Mont HB 171	Apr 26, 2021	Oct 1, 2021	Effective
NE	Neb Rev Stat §28-327 Neb Rev Stat §28-327.01	2019 Neb LB 209	Jun 4, 2019	Sep 1, 2019	Effective
ND	ND Cent Code, §14-02.1-02 ND Cent Code, §14-02.1-02.1	2019 ND HB 1336	Mar 22, 2019	Aug 1, 2019	Enjoined—preliminary injunction granted Sep 10, 2019
OK	63 Okla Stat §1-756	2019 Okla SB 614	Apr 25, 2019	Nov 1, 2019	Enjoined—temporary injunction granted Oct 25, 2019
SD	SD Codified Laws §34-23A-10.1 SD Codified Laws §34-23A-10.4	2016 SD HB 1157 2021 SD HB 1130	Mar 16, 2016 Mar 25, 2021	Jul 1, 2016, Jul 1, 2021	Effective
TN	Tenn Code Ann §39-15-218	2019 Tenn HB 2263	Jul 13, 2020	Oct 1, 2020	Enjoined—temporary restraining order granted Sep 29, 2020
UT	Utah Code Ann §76-7-305 Utah Code Ann §76-7-305.5	Abortion Law Amendments, 2018 Utah SB 118	Mar 19, 2018	May 8, 2018	Effective
WV	W Va Code §16-2I-2 W Va Code §16-2I-3 W Va Code §16-2I-4	2021 W Va HB 2982	Apr 28, 2021	Jul 9, 2021	Effective

Medication Abortion Reversal Law Variation

As of December 31, 2021, 14 states (27%) had MAB-reversal laws enacted. Following publication of Delgado and Davenport’s 2012 case series,³ the first reversal laws were enacted in Arizona and Arkansas in 2015, although Arizona’s 2015 reversal law—which contained explicit references to “reversal”—was repealed and replaced in 2016 with more generic reversal language following backlash from constituents. Over the next 6 years, 12 additional states enacted MAB-reversal laws. Following Arizona and Arkansas, South Dakota enacted its reversal law in 2016, followed by Idaho and Utah in 2018.

Following the 2018 publication by Delgado et al.,⁵ the number of states enacting MAB-reversal laws increased notably. In 2019, Kentucky, Nebraska, North Dakota, and Oklahoma enacted reversal laws, and Tennessee enacted its reversal law in 2020. Lastly, in 2021, 4 additional states—Indiana, Louisiana, Montana, and West Virginia—enacted reversal laws. Of the 14 states with enacted MAB-reversal laws as of December 31, 2021, 10 of these states—Arizona, Arkansas, Idaho, Kentucky, Louisiana, Montana, Nebraska, South Dakota, Utah, and West Virginia—had laws in effect. The remaining 4 states—Indiana, North Dakota, Oklahoma, and Tennessee—had laws that were temporarily enjoined pending litigation. Geographically (Figure 1), 6 of the 14 states (43%) were located in the South (Arkansas, Kentucky, Louisiana, Oklahoma, Tennessee, and West Virginia), 4 (29%) in the Midwest (Indiana, Nebraska, North Dakota, and South Dakota), and 4 (29%) in the West (Arizona, Idaho, Montana, and Utah).

FIGURE 1—

States With Enacted Medication Abortion‒Reversal Laws by Year First Law Enacted and Incidence by Year: United States, 2012–2021

Content Analysis

Tables 2 and 3 display content analysis results regarding the following themes: language describing “reversal”; references to supporting “scientific research”; when, how, and by whom patients are informed; patient actions; penalties for providers or clinics; and state Web site requirements.

TABLE 2—

State Medication Abortion‒Reversal Law Content Analysis—Language, Research, and When and How Patients Are Informed: United States, 2012–2021

State	Reversal Language	References Research	When Are Patients Informed?	How Are Patients Informed?
AZ	Generic language: “the use of mifepristone alone to end a pregnancy is not always effective.”	No	Upon patient contacting clinic	Not specified
AR	Explicit language: “It may be possible to reverse [Mifepristone’s] intended effect.”	No	Preabortion counseling At discharge	Orally, in person (preabortion counseling) In writing (discharge materials)
ID	Explicit language: “interventions, if any, that may affect… the reversal of a chemical abortion.”	No	Preabortion counseling	In writing
IN	Explicit language: “the effects of Mifepristone may be avoided, ceased, or reversed.”	Yes: “Some evidence suggests…”	Preabortion counseling At discharge	Orally, in person (preabortion counseling) In writing (discharge materials)
KY	Explicit language: “to reverse the effects of prescription drugs intended to induce abortion.”	No	Preabortion counseling Receipt of prescription	Orally, not specified (preabortion counseling) In writing (with prescription)
LA	Generic language: “the first pill,… mifepristone, is not always effective in ending a pregnancy.”	Yes: “Research has indicated…”	At discharge Receipt of prescription	In writing
MT	Explicit language: “reversing the effects of abortion-inducing drugs.”	No	Preabortion counseling	In writing
NE	Generic language: “mifepristone alone is not always effective in ending a pregnancy.”	Yes: “Research indicates…”	Preabortion counseling	Orally, in person or over telephone
ND	Explicit language: “it may be possible to reverse the effects of an abortion-inducing drug.”	No	Preabortion counseling	Not specified
OK	Explicit language: “Mifepristone… alone is not always effective in ending a pregnancy. It may be possible to reverse its intended effect.”	No	Preabortion counseling Upon physical visit to clinic (clinic signs) At discharge	Orally, in person or over telephone (preabortion counseling) In writing (clinic signs, discharge materials)
SD	Generic language: “it is still possible to discontinue a drug-induced abortion.”	No	Preabortion counseling At discharge	In writing
TN	Explicit language: “It may be possible to avoid, cease, or even reverse the intended effects of a chemical abortion utilizing mifepristone.”	Yes: “Recent developing research has indicated…”	Preabortion counseling Upon physical visit to clinic (clinic signs) At discharge	Not specified (preabortion counseling) In writing (clinic signs, discharge materials)
UT	Generic language: “aborting a medication-induced abortion.”	Yes: “Research indicates…”	Preabortion counseling At discharge	Orally, in-person (preabortion counseling) In writing (discharge materials)
WV	Generic language: “it may be possible to counteract the intended effects of a mifepristone chemical abortion.”	No	Preabortion counseling At discharge	Orally, in person or via telephone (preabortion counseling) In writing (discharge materials)

TABLE 3—

State Medication Abortion‒Reversal Law Content Analysis—Who Informs Patients, Patient Actions, Penalties, and Web Site Requirements: United States, 2012–2021

State	Who Informs Patients?	What Actions Should Patients Take?	Penalty for Provider or Clinic?	Web Site Requirement?
AZ	Clinic staff	Contact physician	None specified	Yes
AR	Health care professional (physician or physician’s agent)	Search “abortion pill reversal” online	None specified	Yes
ID	Health care professional (physician or physician’s agent)	Contact health care provider	None specified	Yes
IN	Health care professional (physician)	Visit “abortion pill reversal” Web site or call hotline	None specified	None specified
KY	Health care professional (physician, licensed nurse, PA, or social worker)	Contact physician	Provider penalty: denial, probation, suspension, or revocation of license	None specified
LA	Health care professional (physician or physician’s agent)	Contact physician or health care provider	None specified	None specified
MT	Health care professional	Visit “abortion pill reversal” Web site or call hotline	None specified	None specified
NE	Health care professional (physician or PA or RN as physician’s agent)	Visit state Web site	None specified	Yes
ND	Health care professional (physician or physician’s agent)	Contact health care provider	None specified	Yes
OK	Health care professional (physician or physician’s agent; preabortion counseling and discharge materials) Clinic (sign in clinic)	Visit “abortion pill reversal” Web site or call hotline	Financial penalty for clinic or facility	Yes
SD	Health care professional (physician)	Visit state Web site or contact health care provider	None specified	Yes
TN	Health care professional (physician; preabortion counseling) Health care professional (physician or physician’s agent; discharge materials) Clinic (sign in clinic)	Visit state Web site or contact health care provider	Financial penalty for clinic or facility	Yes
UT	Clinic or hospital staff or health care professional (physician, RN, NP, APRN, CNM, genetic counselor, or PA)	Contact physician	Provider penalty: suspension or revocation of license, administrative penalties	Yes
WV	Health care professional (physician or physician’s agent; preabortion counseling and discharge materials)	Contact physician	None specified	Yes

Note. APRN = advanced-practice registered nurse; CNM = certified nurse midwife; NP = nurse practitioner; PA = physician’s assistant; RN = registered nurse.

Reversal language

We first categorized type of language used to describe MAB reversal as either explicit (e.g., “the effects of mifepristone can be reversed”) or generic (e.g., “mifepristone is not always effective”). Eight states’ laws make explicit references to reversal, stating that MABs can be reversed. For instance, Arkansas’s law states a physician must inform the patient of “information on reversing the effects of abortion-inducing drugs.”¹³ Six states’ laws do not specifically mention iterations of the word “reversal,” instead using generic language to imply that MABs can be reversed, as in West Virginia’s law: “it may be possible to counteract the intended effects of a mifepristone chemical abortion.”¹⁴

Reference to scientific evidence or research

Although most states refrain from referencing scientific evidence, 5 include references to research in the laws. Of note, 4 of the 5 laws referencing research were enacted after the 2018 Delgado et al. publication.⁵ Tennessee’s law states, “recent research has indicated that mifepristone alone is not always effective in ending a pregnancy.”¹⁵ Indiana’s law appears to reference the mixed evidence base around reversal, noting,

some [emphasis added] evidence suggests that the effects of Mifepristone may be avoided, ceased, or reversed if the second pill, Misoprostol, has not been taken.¹⁶

When patients are informed

In 12 of the 14 states with MAB-reversal laws, patients must be informed about the possibility of reversal during preabortion counseling. Many states require providers or staff to counsel patients at multiple points throughout the abortion care process, such as during preabortion counseling and at discharge. Seven states require informing patients during preabortion counseling and at discharge, and 1 state (Kentucky) requires informing patients during preabortion counseling and upon receipt of the prescription. Two states— Oklahoma and Tennessee—require clinics to post visible signs in the clinic, passively informing patients upon clinic entrance. Both laws are presently enjoined and, thus, not in effect.

Two states require informing patients at unique points in the abortion care process. In Louisiana, providers must inform patients either at discharge or upon receipt of their prescription, via the following:

• (1)Stapling the disclosure statement to a bag, envelope, or other package that contains misoprostol for the [patient] to self-administer at home.
• (2)Attaching the disclosure statement to a written prescription for misoprostol provided by the physician or the person acting under the physician’s direction.
• (3)Attaching the disclosure statement to the patient’s discharge instructions if the prescription for misoprostol is sent directly to a pharmacy.¹⁷

In Arizona, patients are informed only in the specific circumstance in which a patient who has taken mifepristone, but not misoprostol, contacts an abortion clinic

questioning her decision to terminate her pregnancy or seeking information regarding the health of her fetus or the efficacy of mifepristone alone to terminate a pregnancy.¹⁸

How patients are informed

Twelve states specify that patients should be informed using written or oral communication. Of those 12 states, 11 states require patients be informed in writing during preabortion counseling, at discharge, upon receipt of prescription, or via clinic signs. Seven states require that patients receive the information orally during preabortion counseling, with 6 states requiring in-person or offering the option of in-person or over the phone. Although Kentucky specifies that patients should be informed orally, the law does not specify whether oral communication must be in-person or over the phone. Two states—Arizona and North Dakota—do not specify the way patients are to be informed.

Who informs patients

In 13 states, MAB-reversal laws specify that health care professionals—namely, a physician or advanced practice clinician acting as a physician’s agent—inform patients of the possibility of reversal. While some states, such as West Virginia, specify a “physician or physician’s agent,”¹⁴ other states, such as Kentucky, detail the other medical professionals to whom the law may apply: “a physician, licensed nurse, physician assistant, or social worker to whom the responsibility has been delegated by the physician.”¹⁹ Tennessee’s law requires a physician to inform patients during preabortion counseling, while a physician or physician’s agent reminds patients when providing discharge materials.

Two states—Arizona and Utah— delineate clinic staff as an informing party; Arizona’s law identifies clinic staff as the party who informs patients (i.e., “the abortion clinic staff”),¹⁸ while Utah’s lists clinic or hospital staff as 1 potential party who might inform patients, along with a physician or physician’s agent (i.e., “a staff member of an abortion clinic or hospital, physician, registered nurse, nurse practitioner, advanced practice registered nurse, certified nurse midwife, genetic counselor, or physician’s assistant”).²⁰ Lastly, 2 states—Oklahoma and Tennessee—include clinics as an informing party via in-clinic signs (both laws were enjoined at the time of our study). Oklahoma’s law states,

Any private office, freestanding outpatient clinic, hospital or other facility or clinic in which medication abortions… are provided shall conspicuously post a sign… so as to be clearly visible to patients.²¹

What actions patients should take

Nine states instruct patients to contact a physician or health care provider for additional information, sometimes noting to patients that “time is of the essence.” Three states instruct patients to visit a state-managed Web site to gain access to “abortion pill reversal” information services, including a Web site (https://www.abortionpillreversal.com) and telephone hotline run by the Abortion Pill Rescue Network at Heartbeat International, a large international antiabortion organization. For example, Nebraska’s law states, “information on finding immediate medical assistance is available on the web site of the Department of Health and Human Services”²²; upon visiting this Web site, visitors are directed to the “abortion pill reversal” telephone hotline. An additional 3 states instruct patients to contact “abortion pill reversal” information services and provide the contact information directly, such as in Montana’s law, which states:

Information on the potential ability of qualified medical practitioners to reverse the effects of an abortion obtained through the use of abortion-inducing drugs is available at www.abortionpillreversal.com, or you can contact (877) 558-0333 for assistance in locating a medical professional who can aid in the reversal of an abortion.²³

Finally, 1 state—Arkansas—instructs patients to “search ‘abortion pill reversal’ online.”¹³

Provider or clinic penalties

Four states include specific penalties for providers or clinics offering abortion services that do not comply with MAB-reversal laws. Two states, Kentucky and Utah, detail penalties for individual providers who do not comply with the reversal law, including denial, probation, suspension, or revocation of a provider’s medical license or administrative penalties. Two additional states, Oklahoma and Tennessee, specify financial penalties for clinics that fail to comply with the reversal law. In Tennessee, any

facility or clinic that negligently fails to post a sign… [shall receive] a civil penalty of ten thousand dollars ($10,000). Each day on which an abortion… is performed… during which the required sign is not posted is a separate violation.¹⁵

State-managed Web sites

Lastly, 10 states require that state departments of health develop and maintain public Web sites providing an online version of preabortion counseling materials, including reversal information. Laws in the remaining 4 states do not specify a Web site requirement.

DISCUSSION

Following the initial 2012 publication on MAB reversal,³ the number of states with MAB-reversal laws enacted grew from zero in 2012 to 14 in 2021. The largest annual changes in laws occurred in 2019 and 2021, following the 2018 publication by Delgado et al.,⁵ during which 4 states enacted MAB-reversal laws. Ten of the 14 states with reversal laws are in the Midwest or South, regions of the country with the most restrictive environments toward abortion.^24,25 Content analysis revealed that state laws often use explicit language detailing the possibility of reversal and require information be provided to patients orally or in writing during preabortion counseling or at discharge, usually by a physician or physician’s agent. State laws largely instruct patients to contact a health care provider for more information on reversal or to visit an “abortion pill reversal” Web site and telephone hotline, and require that a state agency post information about reversal on a state-managed Web site.

Public policy scholar Paul Cairney proffers that policymakers rely on rational and irrational solutions to make policy decisions, balancing the prioritization of certain sources of information (“rational solutions”) with emotions, gut feelings, beliefs, and habits (“irrational sources”).²⁶ In the case of MAB reversal, antiabortion legislators employ both rational and irrational sources when enacting these policies, combining the rational source of Delgado’s and others’ work on MAB reversal with their own “irrational” antiabortion beliefs. In addition, antiabortion advocates and lobbyists have made and will continue to make concerted efforts to rally policymakers to enact reversal legislation. Groups such as the National Right to Life Committee, which actively advocate for restrictive antiabortion legislation, have named MAB-reversal laws as one of their key legislative targets. The relatively swift proliferation of MAB-reversal laws in US states highlights the increasing efforts at the state legislative level to restrict abortion access and the tendency for policymakers to ground antiabortion policy in moral and religious arguments²⁷ and support from antiabortion activists, despite positive public support for abortion access remaining steady.^27–30

On June 24, 2022, the Supreme Court of the United States overturned the constitutional right to an abortion established in Roe v. Wade in their ruling on Dobbs v. Jackson Women’s Health Organization. As of September 30, 2022, of the 14 states with MAB-reversal laws, 7—Arkansas, Indiana, Kentucky, Louisiana, Oklahoma, South Dakota, and Tennessee—have banned all abortions, with very limited exceptions.³¹ Four additional states—Arizona, North Dakota, Utah, and West Virginia—have either pre-Roe bans or trigger bans that are currently enjoined and, thus, not in effect.³¹ Abortion remains legal in the remaining 3 states—Idaho, Montana, and Nebraska—although state environments are changing rapidly and could shift at any time.

The post-Dobbs landscape has shifted the importance of MAB-reversal laws considerably. In states with complete bans in effect, clinicians are unable to prescribe mifepristone or misoprostol for a MAB, thus rendering MAB-reversal laws moot. Exceptions to these complete bans are extremely limited, with states typically allowing abortions only to save the pregnant person’s life³¹—a scenario in which an abortion would likely be procedural rather than medical. However, in the 4 states with abortion bans that are currently enjoined and not in effect, or in the 3 states where abortion remains legal, MAB-reversal laws remain significant.

Furthermore, in states that have not yet enacted or do not have the legislative capacity to enact total bans, or in states that have begun or are expected to receive a surge of out-of-state patients, MAB-reversal laws will likely become increasingly important mechanisms for antiabortion policymakers. For instance, at least 3 additional states (Georgia, Iowa, and Maryland) introduced MAB-reversal laws during the pre-Dobbs 2022 legislative session. These trends, along with the increasing fervor of antiabortion legislators and advocates to eliminate abortion access, suggest that MAB-reversal laws are an important player in the antiabortion policymaking agenda that will continue to appear in future legislative sessions.

Implications for Patients, Practice, and Policymaking

Our findings have important implications for the health of patients, providers, the patient‒provider relationship, and policymaking, particularly in this post-Dobbs era. Regarding patients, MAB-reversal policies have the potential to increase stigma and shame around receiving an abortion, decrease patient empowerment and self-efficacy, and make patients vulnerable to physical complications.

First, reversal policies are rooted in abortion stigma.³² Use of language referencing the possibility to “reverse,” “correct,” or “counteract” the effects of mifepristone conveys the idea that choosing a MAB is a mistake—although people seeking abortions have high degrees of certainty about their decisions^33–35—and, therefore, lawmakers are giving patients an opportunity to correct their error. Abortion stigma leads to experiences of stress, shame, and guilt among abortion patients, resulting in reduced self-efficacy around decision-making, decreased perceptions of social support, and increased psychological distress.^36,37

Second, some states instruct patients interested in reversal to visit the “abortion pill reversal” Web site run by the Abortion Pill Rescue Network at Heartbeat International, an international antiabortion association that reportedly supports the largest network of crisis pregnancy centers—antiabortion organizations posing as health care clinics that attempt to dissuade people from considering abortion³⁸—in the world. This Web site and its associated hotline use coercive, antiabortion messaging (e.g., “Time is precious, and so is your baby—call us today”; “We are the agile guardians of that precious moment in time when a woman chooses to give her unborn child a chance to fight for life”) to transmit misinformation about the possibility and evidence behind reversal. Further exposure to misinformation and stigmatizing messaging may reduce patient self-efficacy and increase experiences of shame or guilt around their decision,³⁹ which may increase a patient’s drive to pursue reversal.

Third, MAB-reversal laws in 10 states require publication of information about MAB reversal, along with other biased statements about abortion, on state department of health Web sites. State departments of health are generally perceived by the public to be trusted sources of information for public health and health promotion⁴⁰; thus, state-sanctioned promotion of abortion misinformation has great potential to mislead and endanger the public. Requiring promotion of medically inaccurate information such as MAB reversal compromises the integrity of entities with a mission to promote and protect the public’s health.

Lastly, MAB reversal may result in increased risk of physical complications, including severe hemorrhage. As Creinin et al. assert,

patients who use mifepristone for a medical abortion should be advised that not using misoprostol could result in severe hemorrhage, even with progesterone treatment.^6(p162)

Poor outcomes following MAB reversal have the potential to negatively affect the health and well-being of patients seeking a MAB, particularly those who are Black, other people of color, or those of lower socioeconomic status, groups that are disproportionately affected by restrictive abortion policies and experience the highest maternal mortality rates.^41–44

In addition, this study has important implications for provider practice and the patient‒provider relationship. MAB-reversal laws are another example of legislation requiring clinicians to transmit misinformation to their patients. Many states require inclusion of other inaccurate or misleading information in preabortion counseling, such as inaccurate statements about mental health effects of having an abortion, fetal pain, or purported links between receiving an abortion and breast cancer.⁴⁵ These laws are burdensome to providers; interfere with their ability to provide comprehensive, patient-centered care⁴⁶; violate the accepted standards of informed consent; and negatively affect the trust and rapport of the patient‒provider relationship.⁴⁷ Although MAB-reversal laws similarly intrude on and undermine the patient‒provider relationship, they further jeopardize the role of provider as healer and violate medical ethics by requiring providers to impart information about an experimental procedure that may cause patients harm.

Finally, study findings have clear implications for the post-Dobbs policymaking sphere. MAB-reversal laws reflect the general trend for antiabortion policy to be grounded in unsound science and to promote misinformation. As noted earlier, MAB-reversal laws will likely become increasingly popular among antiabortion policymakers and advocates seeking to restrict abortion to the greatest extent possible, particularly in states without total abortion bans. When opposing enactment of additional MAB-reversal laws and leading efforts to repeal existing reversal laws, policymakers should focus on the weak scientific evidence behind these policies, partnering with clinicians and researchers to debunk the science. Furthermore, policymakers should collaborate with community members, organizations, advocates, clinicians, and researchers to promote egalitarian policymaking grounded in high-quality evidence and person-centered research around abortion, which centers the communities traditionally left out of policymaking.

Limitations

There are some limitations to our analysis. First, the inclusion of enjoined laws in this analysis may artificially inflate the prevalence of MAB-reversal regulation in the United States. However, because policy implementation is often ambiguous and enjoined laws may influence patient and provider beliefs and experiences, their inclusion was important to this analysis. Second, the laws reviewed here do not reflect the implementation or enforcement of these policies, which may vary from how laws are written; thus, we can only infer how these laws influence provider practice and patient experiences. Third, this analysis focused only on enacted legislation; it does not capture legislation that was introduced in but not enacted by a state legislature. Thus, this analysis does not fully reflect the frequency with which MAB-reversal legislation was introduced into state legislatures.

Conclusions

In this analysis, we critically examined an understudied and dangerous means by which state legislators regulate abortion. We explored the path between scientific evidence and policymaking, highlighting a case in which sensationalized research, denounced as unsafe and of low quality by experts, nevertheless quickly inspired state antiabortion legislation, requiring the transmission of medically inaccurate information to patients. Our findings highlight the rapid proliferation of MAB-reversal laws and the various ways in which states regulate informing patients about reversal. Findings from this study can provide evidence for the concerning relationship between antiabortion science and policymaking, stimulate further rigorous research of historical legal data, and inform abortion policymaking, including the repealing of MAB-reversal laws.