In a St. Louis high-rise hotel last April, health-care workers filed into a conference room to learn about the myth of undoing a pill-induced abortion, also called abortion pill reversal. The workshop, hosted by the anti-choice giant Heartbeat International, promised nurses in attendance that they could earn continuing education credits from a state some 1,700 miles away: California.
Missing from the conference materials was any disclosure saying that the medical establishment, including the American Congress of Obstetricians and Gynecologists (ACOG), rejects the so-called science behind abortion pill reversal. Instead, Heartbeat International displayed the medical imprimatur of the Golden State: “Provider approved by the California Board of Registered Nursing, Provider Number CEP 16061 for 1.25 contact hours for each workshop.”
How has Heartbeat International, along with other anti-choice organizations, co-opted a narrow area of health-care law in one of the country’s most progressive states? The answer exposes regulatory holes in the post-graduate education of California nurses.
Continuing education credits are required of nurses and doctors to maintain licensure in California and other states. The rationale is to ensure that health-care professionals, after the completion of their formal education, remain abreast of medical developments in order to safeguard patients and to, when appropriate, shape their care.
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Heartbeat International and other anti-choice groups have treated abortion pill reversal, both in courses offering these education credits and elsewhere, as if it’s a medical fact—but the science behind it is scanty, at best.
A single 2012 paper in Annals of Pharmacotherapy claimed to have reversed the medication abortions of four of six women included in the study.
A medication abortion, typically performed early in a pregnancy, involves the administration of two pills: mifepristone and misoprostol. Mifepristone blocks receptors for the hormone progesterone, causing the embryo to detach from the uterine wall, while misoprostol causes the uterus to contract and expel the pregnancy. The FDA-approved treatment, according to the Guttmacher Institute, accounts for more than one-quarter of abortions before nine weeks.
But by administering dosages of the hormone progesterone after mifepristone, anti-choice doctors claim they can “reverse” an abortion.
Experts say the six cases cited in the Annals of Pharmacotherapy paper are insufficient to draw conclusions. ACOG, a professional organization of 58,000 OB-GYNs and women’s health-care professionals, is dismissive of the purported treatment.
“There is really no clear evidence that this works,” said Dr. Daniel Grossman, ACOG fellow and director of Advancing New Standards in Reproductive Health, a research group at the University of California, San Francisco, in an interview with MedPage Today about the “science” behind abortion pill reversal.
Four years ago, when Heartbeat International applied to the California Board of Registered Nursing to teach continuing education courses, it listed Debbie Bradel, RN, as an instructor. Bradel is one of the foremost advocates of abortion reversal and has been for years. She is on the staff of the “abortion pill reversal program” at a San Diego area clinic, which claims to have a network of hundreds of doctors nationwide who advocate for the medically questionable procedure.
Bradel was not made available for an interview with Rewire, but her supervisor, medical director Dr. George Delgado, described the course, “Abortion Pill Reversal and Your Clinic,” which Bradel taught last year at the April St. Louis Heartbeat International conference. The class, Delgado said in a phone interview, was “given to licensed pregnancy centers for women who might be interested in changing their minds after taking the first pill.”
Delgado offered his own statistics to back the treatment, saying abortion pill reversal has resulted in about 145 births, with a success rate of 55 percent. He said between 75 and 80 women nationwide are pregnant right now, having undone their abortions with dosages of progesterone.
The class that Bradel taught, Delgado said, “describes the process for the reversal in great detail.”
When Rewire showed the course description to Diana Taylor, professor emerita with the UCSF School of Nursing, she said it was difficult to know the true nature of the class without a syllabus or course objectives, but she noted that the overall tone seemed skewed toward persuading, rather than informing.
“It made me think they’re re-framing their purpose, which is to keep women from having abortions,” Taylor said. “I think that we would really need to see those courses. If I were in that classroom, I guess I would be listening very carefully to how they talk about implementing these skills … because it’s counter to [the] nursing code of conduct to not give full information.”
Delgado did not respond to Rewire’s request for class materials, such as a syllabus or learning objectives, by deadline.
A Loophole Welcomed by the Anti-Choice Movement
California is something of a standard-bearer for reproductive rights. The state in recent years passed a law allowing women to obtain birth control from pharmacists and has forced crisis pregnancy centers (CPCs), faith-based facilities that often masquerade as abortion clinics, to make disclosures about the availability of abortion care and birth control services. And in what may serve as a model for municipalities nationwide, San Francisco demands truth in advertising for CPCs, which frequently use misinformation to dissuade women from ending their pregnancies.
Heartbeat International, in contrast, is known for its nationwide billboards—“Pregnant? Scared? Need Help? Call us…”—designed to ensnare women seeking abortions. The Ohio-based organization is the umbrella group for 1,800 CPCs on six continents with the singular goal of “saving babies.”
That Heartbeat International is teaching nurses about abortion pill reversal capitalizes on something of a loophole in California law.
The California Board of Registered Nursing is part of the state Department of Consumer Affairs, which encompasses 40 boards, bureaus, committees, and a commission that each year, according to a state audit, process more than 350,000 applications for professional licensure and an estimated 1.2 million license renewals.
The law requires the state Board of Registered Nursing to vet nursing continuing-education providers, which range from private companies to universities. But it leaves it to approved providers to ensure the class material is lawful.
To become a state-approved provider, applicants complete a six-page application, including instructors’ qualifications and class descriptions, such as content and objectives. By law, the class content, according to the state Board of Registered Nursing website, “must be related to the scientific knowledge and/or technical skills required for the practice of nursing, or be related to direct and/or indirect patient/client care.”
Heartbeat International on its application, which Rewire received a copy of through a public records request, listed a single, benign-sounding course: “Knobology Applications: Or How to Get Better Pictures.”
Applications are then reviewed by licensed registered nurses, explained Christina Sprigg, chief of licensing and administrative services with the state board.
“We do not approve courses, we only approve the providers,” Sprigg said in a phone interview with Rewire.
Gaining approval appears to be almost a slam dunk. Figures provided by the California Board of Registered Nursing indicate that from 2012 to 2014, it received 764 applications and approved 82 percent. The board doesn’t outright deny applications, an agency spokeswoman explained in an email, but instead rates applicants as deficient, giving them up to two years to remedy any shortcomings needed to gain approval.
Once approved, providers essentially police themselves. Audits are rare and officials said they have never audited Heartbeat International, or two other major anti-choice providers, Care Net and the National Institute of Family and Life Advocates, whose applications were approved years ago when Arnold Schwarzenegger was governor.
In response to Rewire’s request for the number of total audits performed between 2012 and 2014, the agency said it “does not have any data on the number of provider audits completed for these periods of time.”
The board’s Sprigg put it simply: “It’s very few, only because we don’t have the staff to conduct the audits.”
It’s difficult to say whether California’s lax practices are standard across the country, or an outlier. The absence of a national governing body over continuing education means that regulation is left up to individual states, explained a spokeswoman with the National Council of State Boards of Nursing, an advisory body.
Problems with the California Board of Registered Nursing are not new. Investigations by ProPublica and the Los Angeles Times found widespread failures to discipline nurses for misconduct. The board took more than three years, on average, to investigate and discipline errant nurses, according to its own statistics, a process that in other states typically takes a year or less.
Dr. Pratima Gupta, a reproductive health advocacy fellow with New York City-based Physicians for Reproductive Health, worries that the system leaves California open to political exploitation.
“I think the concern is there isn’t enough bandwidth to do quality control, so there’s incorrect information out there,” Gupta said in a phone interview.
Allowing state-approved providers like Heartbeat International to dispense biased medical information, Gupta contends, is a public health problem.
“These courses are giving continuing-education nursing credits and they are disseminating incorrect information,” Gupta said.
Rewire has provided the state Board of Registered Nursing with the descriptions of the abortion pill reversal class and others offered by anti-choice groups that the state has approved as continuing education providers. The board, in written responses, repeatedly cited state law that said the agency is not required to approve courses.
The agency passed the buck to the continuing education providers, writing “California Code of Regulations section 1454 requires the approved provider to accept full responsibility for each course taught.”
Amy Everitt, vice president of NARAL Pro Choice California, believes anti-choice providers are using the state to “create that veneer of legitimacy.”
“What we really need is tighter standards so no one is getting credit for medically inaccurate training,” Everitt said in a phone interview. “I think it presents a health-care problem for women in California when they think they are getting medically accurate information, and they are not.”
“It’s Obviously Going to Impact Women’s Health”
Care Net is a massive anti-choice umbrella organization based in Virginia. Like Heartbeat International, its stock in trade is convincing women to remain pregnant, which it does through thousands of affiliated CPCs spread across the country. California approved its application to teach continuing education nursing classes nine years ago.
Once a provider gains state approval, maintaining that status is simple. The provider pays a $300 renewal fee every two years and must confirm that information contained in the initial application remains the same, Sprigg from the Board of Registered Nursing explained.
Care Net, like Heartbeat International, touts its status as a California-approved continuing education provider. Its annual conference brochure last year included this note: “Care Net is approved by the California Board of Registered Nursing to provide continuing education contact hours for nurses. Provider Number: CEP14950.”
Appearing in the same brochure was a listing for a continuing education course: “Fetal Pain: What’s the Evidence?”
Anti-choice lawmakers in Arizona and elsewhere have latched onto the notion of fetal pain in failed attempts to ban abortion after the first trimester. The medical establishment agrees that the fetal nervous system lacks the development necessary to feel pain until the third trimester. ACOG has said that fetal pain is unlikely before the third trimester and “no studies since 2005 demonstrate fetal recognition of pain.”
The instructor for “Fetal Pain: What’s the Evidence?” was Dr. Sandra Christiansen; her name also appeared on Care Net’s nine-year-old state application. But the application neglects to mention the fetal pain class, and so it’s difficult to say precisely what Christiansen may have taught nurses at the Care Net conference in San Diego last year.
What is clear is that Christiansen gave testimony two years earlier in support of Maryland’s Pain-Capable Unborn Child Protection Act, an attempt to ban abortion care after 20 weeks.
Christiansen didn’t respond to requests for comment.
Pinning down the number of nurses who have taken classes taught by advocates like Christiansen is impossible. The state doesn’t keep a tally of the courses that nurses submit for continuing education credit. It is clear, however, that the classes, worth only 1.25 “contact” hours, account for only a fraction of the 30 hours that California registered nurses must complete every two years to maintain licensure.
Even so, Gupta, a physician, worries that these classes are introducing bias, or worse, at a time when evidence-based reproductive health care is under attack by legislators and powerful and well-funded anti-choice organizations. California, until now, had been seen as a bulwark against this tide of medical misinformation.
“It’s obviously going to impact women’s health in that a nurse is receiving information that he or she is then disseminating to their patients,” Gupta said. “I think that’s the concern.”