The People of the State of California v. Heartbeat International and RealOptions

The Basics

In California, The State Attorney General (A.G.) Rob Bonta is suing two pro-life pregnancy help organizations, Heartbeat International (HBI) and RealOptions. The Thomas More Society (TMS) is representing both of the pregnancy help orgs in this case.

It’s an interesting case, because A.G. Bonta is suing them for talking about abortion pill reversal (APR) — not doing APR.

Basically, he’s big mad that APR is an option, so he is attacking how it is offered and advertised in a circuitous attempt to shut down all APR attempts in CA.

The main “causes of action” the A.G. is taking against HBI and RealOptions are:

“False and Misleading Statements.” He is accusing these pro-life orgs of coercing women to undergo APR by lying to them about how APR works, including specifically the use of the word “reversal”; its rate of effectiveness of continuing a pregnancy and how many babies have been saved by the process so far; how long after and after which types of abortion medications APR may still work; and the claim that APR is not harmful to the baby.
“Unlawful, Unfair, and Fraudulent Business Practices.” A.G. Bonta is accusing HBI and/or RealOptions of fraudulent practices when they talk about any of the items listed in point 1. Additionally, he says RealOptions commits fraud when they don’t tell women that “APR can cause severe, life-threatening bleeding.”

As part of his complaint, A.G. Bonta makes the tired, inaccurate claim that medical abortion is safer than taking “Penicillin, Viagra, and… Tylenol.” He relies on information from the abortion pill manufacturer, Danco Labs, to state that it is extremely rare for a woman to change her mind after taking the first abortion pill. He also states there is no credible evidence that APR works or that it is safe — that the pro-life side only has “flawed and misleading reports to support their claims.”

He cites a paper published by Dr. Mitchell Creinin to back up his claim that APR is actually harmful to a woman’s health. Additionally, he claims that HBI and RealOptions do not inform women that there could be negative side effects to APR that we do not yet know about yet because of “the absence of long-term data.”

Finally, he makes an emotional appeal to Alameda County’s Superior Court of the State of California. He claims HBI and RealOptions, “use emotionally vulnerable individuals who come to them in the midst of a gut-wrenching life choice as subjects in experiments to determine whether APR is safe and effective. Defendants attract these individuals through multiple misrepresentations and pressure them by claiming they must start treatment as quickly as possible, further exploiting these individuals’ heightened emotional state.”

Ah, the irony. But we’ll get to that.

Quick Timeline

The trial for the lawsuit began on June 24, but the story goes back quite a bit farther. On Sep 24, 2023, A.G. Bonta filed his lawsuit. In Feb 2024, TMS asked the court to throw the lawsuit out, but after an initial hearing in June 2024, the court decided to not throw out the case. Two years later, and here we are, 14+ days into the trial hearing.

Background Info

APR is available for women who have started a medical abortion (an abortion involving drugs, not surgery) but changed their minds and want to continue their pregnancy. You can learn more about the science of APR here (in detail).

In general: progesterone helps maintain the lining of the uterus, while mifepristone, typically the first medication taken in a medical abortion, blocks progesterone receptors in the uterus so that the lining breaks down. This breakdown of the uterine lining is what kills the human embryo or fetus. But give enough progesterone to the body, and it will shove out the mifepristone and take its rightful place in the progesterone receptors and continue to maintain the lining of the uterus.

Progesterone has long been given to help women carry to term or prevent a miscarriage.

Heartbeat International manages the APR hotline, which connects women seeking APR to a nurse and an APR provider. RealOptions has several state-licensed pregnancy help centers in southern CA, and APR is one service among many that they provide. Calling the helpline, being connected to and talking to a nurse, being connected to an APR provider, getting ultrasounds, and getting the actual progesterone are all services offered completely for free.

A.G. Bonta wants to stop APR from being offered in CA, and controlling speech is the route he’s trying to go. Nowhere in the complaint does he directly ask for the pro-life organizations to stop offering APR altogether; instead, he focuses on what these orgs can say about APR. If he wins the suit, he could bankrupt these organizations, which would result in what he really wants — no APR offered in CA and no hotline for any woman in the country to call.

So Far

A.G. Bonta submitted his trial brief first, on June 17th. HBI and RealOptions, via TMS, submitted their trial brief on June 24th.

The pro-life trial brief clearly laid out how A.G. Bonta’s complaints have no basis — chiefly because the A.G.’s arguments rests on the speech (concerning APR) being commercial, but these nonprofit orgs make no money off the APR process — and I would encourage people to read it for themselves.

The TMS brief also addresses the A.G.’s claims regarding APR safety and effectiveness in the brief, as well as the supposed validity of the evidence the A.G. presents to try to prove the harm of APR. I’ll go through some of those highlights below, because what was revealed in discovery and during the trial chips away at some favorite pro-choice rhetoric concerning APR.

Notably, Paul Jonna, TMS Special Counsel, pointed out in the Defense’s opening statement: “After years of investigation and discovery, the Attorney General has not been able to produce a single complaint from a single patient.” However, multiple women have taken the stand for the Defense to talk about their positive experience with APR, from being connected with a provider to giving birth to their much-loved and much-wanted children, and how they were taken care of in between.

There have been 14 trial days so far, with various witnesses taking the stand, including:

The State’s Expert Witness, Dr. Mitchell Creinin (more on him and what he has revealed below) — to try to debunk APR
The State’s statistic expert, Dr. David Glidden
The State’s marketing expert, Professor Briony Swire-Thompson
Erika Carrillo, a mom who called the APR hotline and now has an almost 10-year-old son.
Najia Najera, a woman who did the APR protocol, had video of her deposition shown in court
Dr. Mary Davenport, MD, OB/GYN, the Medical Director for RealOptions
Christa Brown, BSN, RN, LAS, the Senior Director of Medical Impact at HBI (oversees the abortion pill rescue network for HBI)
Jor-El Godsey, President of HBI
Dr. Elena Kraus, MD, PhD, specializing in maternal-fetal medicine
Dr. Michael J New, Assis. Professor of Practice at Busch School of Business
Laura Muñoz, PhD, Professor of Marketing at University of Dallas

What Has Been Revealed

In his Complaint and trial brief, AG Bonta relies heavily on ACOG statements regarding APR and the 2020 study by Dr. Mitchell Creinin to substantiate his case.

Any time you see someone claim APR does not work or is actually harmful to women, they are likely referring to the 2020 Creinin study or the ACOG statements about APR, written in large part by Dr. Creinin and Dr. Grossman.

Some conc e rns, critiques, and responses have been offered concerning the Creinin study and the pro-choice outrage at APR in general.

Additionally, the blatant bias of Dr.s Creinin and Grossman for abortion over APR should not be ignored when reading papers obviously trying to discredit APR.

Dr. Grossman is the Director of ANSIRH, a very abortion-friendly organization. He himself is extremely pro-choice: “He focuses his research on both clinical and social science studies aimed at improving access to contraception and safe abortion in the United States, Latin America, and sub-Saharan Africa.” He is a professor at UCSF; he investigates how TX abortion laws negatively impact women’s reproductive health; he was VP of research and is currently a senior advisor for Ibis Reproductive Health, an abortion advocacy and research group. Earlier in his career, he was a Health Specialist in Mexico City with the Population Council, another abortion-friendly organization.

Dr. Creinin, as the financial disclosure on his 2020 publication states, “is a consultant for Danco Laboratories, providing medical consultation for clinicians that contact Danco with questions regarding mifepristone.” Danco manufactures mifepristone. Dr. Creinin works at UC-Davis, where he is both a Distinguished Professor and the Director of Complex Family Planning Fellowship. His research “focuses on new contraceptive technologies, management of miscarriage, and abortion techniques, all aimed to improve the quality of care available to patients here and in lower and middle-income countries.”

So both Dr. Grossman and Dr. Creinin personally and professionally support abortion; they both are interested in expanding abortion access in economically disadvantaged countries. Is this sounding kind of…yucky? Kind of population-control-y? That’s because it is.

AG Bonta builds much of his case by using publications from authors that are not merely abortion-friendly, but who have vested professional, financial interest in providing abortions and expanding abortion access. So what might happen if the validity of one or more of his pieces of evidence is shown to be deeply flawed?

Revelations with Dr. Crenin

He’s Kind of Eugenics-y

Remember the research interests of Dr. Creinin and thinking they sound kind of yucky? Well, as Thomas More Society reports, it’s probably because he is all about population in poorer countries:

“Near the end of cross-examination, the court heard about Creinin’s broader worldview. He co-authored a 2020 paper in the journal Contraception that explicitly builds on Paul Ehrlich’s The Population Bomb—the 1968 book widely regarded as a foundational text of the modern population-control movement. The paper praises Ehrlich’s warnings about ‘unchecked population growth’ and adopts his environmental-impact formula to argue that population reduction is the key variable.

“Creinin and his co-author write that ‘family planning’—their term for abortion and contraception—is ‘the most humane and viable strategy for human survival,’ that ‘both rich and poor nations have a responsibility to limit family size,’ and that the world ‘cannot sustain … high fertility in poor nations.’ To achieve this, they argue countries must make abortion widely available. These are not the views of a disinterested scientist—they place the AG’s expert squarely within an ideological tradition that has long advocated population control in developing nations through expanded abortion access.”

I read the full article TMS referenced, which is behind a paywall, to make sure the quotes pulled accurately represented the authors’ views as TMS explained them. TMS is being truthful.

Population control for the poors is typically lumped under the umbrella term, “eugenics”; totally the bias and ideology I would want my court case resting on!

He misrepresented data and lied in his 2020 study

In his 2020 study that is often brought up to show APR does not work and is in fact harmful to women, he misrepresented data and just plain lied.

He claimed his study was double-blind. Whether you can only read the free preview or the full article, he states in writing that the study is “double-blind.” A double-blind study compares 2 or more items with each other, such as real medication vs a placebo, where neither the person taking the medication nor the person giving it out know whether the medication is the real thing or the placebo. However, internal emails between him and the Investigational Drug Service (who would make the placebo pills) reveal that it was not a double-blind study. The placebo pill looked too different compared to the progesterone pill; at least the pharmacist giving out the medication would know the difference; I personally suspect a savvy patient would also be able to find out.

He misrepresented his data by omitting data that undermined his results. He responded to a peer reviewer of his 2020 article that he personally estimated the chance of continuing pregnancy after taking mifepristone and then just not taking misoprostol as “mostly likely just 8 percent.” However, he did not want to mention that in his paper (and he did not). Keeping out this estimate in a paper comparing the rate of pregnancy continuation using APR to a placebo is withholding key information to push a specific narrative.

In his 2020 paper, he had to stop the study earlier than he wished due to too many complications. There were 3 patients labeled in the Abstract as having “Severe hemorrhage requiring ambulance transport to hospital occurred in three patients,” 1 within the progesterone group and 2 within the placebo group.

This exact phrasing is not used later in the paper, but it is important to note, because the Abstract is the part of the paper not hidden behind a paywall — the part of the paper anyone and everyone who references it can see.

However, medical records show that the woman within the progesterone did not experience severe hemorrhage! She instead was listed as having minor vaginal bleeding and a spontaneous abortion (medical speak for miscarriage) with no complication. She did not need a blood transfusion.

Medical records also show that one of the women in the placebo group did not require ambulance transit to the hospital, instead walking to the ER on her own.

There was more revealed that TMS reported on here.

The Irony

AG Bonta is super concerned about women, he says in his lawsuit. Remember what he said? HBI and RealOptions “use emotionally vulnerable individuals who come to them in the midst of a gut-wrenching life choice as subjects in experiments to determine whether APR is safe and effective. Defendants attract these individuals through multiple misrepresentations and pressure them by claiming they must start treatment as quickly as possible, further exploiting these individuals’ heightened emotional state.”

So funny, because these statements could be made about abortion, especially medical abortion.

“Emotionally vulnerable individuals” go to an abortion provider “in the midst of a gut-wrenching life choice.” The abortion process and any information on gestational development or fetal development is talked about in euphemistic terms, hiding the worst of what might happen with abortion pills (it’s just a heavy period, it’s totally safe) and glossing over, hiding, or lying about prenatal human life and development (it’s just tissue, it’s not a baby, it’s not alive). Women are told APR is not a thing. Abortion providers “pressure” women to start the abortion “as quickly as possible,” even at the risk of informed consent. Abusive men exploit the ease of getting abortion pills to force unknown abortions on the women they get pregnant. Comment end

If APR is a worthless lifeline to offer women, so is abortion.

And One More Thing…

During the litigation process, HBI had to give the State some data. HBI handed over the “full deidentified dataset — 8,800 patient entries.” This is 8,800 APR cases; a case represents each time a woman starts the APR process.

As TMS reports, “The data showed that out of 8,800 cases, only three women needed transfusions (and two of those hadn’t taken their progesterone) [.00034%], or that there were just 11 hospital admissions [.0013%] and 88 ER visits [.010%]. When asked whether that data, if accurate, would help show APR is safe, Creinin conceded: ‘If the data was true, yes.’”

Even ignoring effectiveness, the data at least show that APR is safe – potentially significantly safer than expectant management, as the ACOG suggests and as is the current standard of care. For that reason alone, APR should be a valid medical option for a woman who does change her mind about a medical abortion. Even if her baby has no higher chance of survival by using the APR protocol, the woman herself has a better chance of avoiding the ER, a hospital admission, and severe hemorrhaging if she undergoes the APR protocol.

Conclusion

If the AG truly cared about women’s health and wellness, he should be encouraging APR.

APR is provided free of charge via charity organizations, so it’s not like State resources are being used up. APR also seems to reduce the chance that women who change their mind about medical abortion have to visit the ER or hospital because it helps prevent the severe bleeding that mifepristone induces.

APR is free for women and the State, it’s better for women than the current standard of care, the marketing surrounding APR is not false or misleading, APR is completely legal, and the State cannot produce a single actual witness who went through APR and was harmed by it… so why, exactly, does AG Bonta want to stop pregnancy help organizations from talking about APR?

His personal and political bias is showing, and it’s potentially getting in the way of women having more pregnancy options and better health outcomes (under specific circumstances).

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