On June 30, 2013 Ohio Governor John Kasich signed into law a state budget with numerous inclusions restricting various women's health services. The budget bill redefined pregnancy as beginning with fertilization, timed from the first day of the last menstrual period. It requires that women who could be pregnant according to this definition and who seek prescribed contraception must receive written notification by healthcare providers that there is no fetal heartbeat, which necessitates that they undergo ultrasound screening followed by a mandated 24-hour waiting period. Severe penalties associated with failure to comply could lead healthcare providers to perform unnecessary transvaginal ultrasounds because an abdominal ultrasound may not detect a fetal heartbeat within the first trimester. The bill requires that healthcare providers follow a prescribed script; failure to do so is grounds for revocation of professional licensure.

For individuals who rely on natural family planning to space or avoid pregnancies, or couples trying to become pregnant, misinformation about the onset of pregnancy that healthcare providers are required to disseminate may be extremely confusing and could subvert the efforts of even highly motivated couples. Maternal overestimation of gestational age by up to 2 weeks could be detrimental to health outcomes of preterm infants.

In states where legislatures are extending their reach to establish healthcare practice requirements, nurses need to engage in dialog with their state boards of nursing and their professional associations to determine the appropriate response to mandates that contradict established, evidence-based professional practice standards. Professional associations' committees on legal affairs need to provide guidance to members related to both their own legal protection and provision of the best possible evidence-based care for their clients.

Numerous outcomes of this legislation warrant tracking. What is the cost of one or more ultrasounds, and will insurers pay when there is no evidence-based indication for them? How much time is added to a well-woman visit, how are personnel in primary care settings affected when the nation faces a shortage of primary care providers, and how has the provision of other health services been affected by this requirement? In terms of maternal-child outcomes, what are its effects on contraception utilization, the birth rate, unintended pregnancy rates, pregnancy rates among and on rates of conception among pregnancy-seeking couples? What is the cumulative cost of changes in maternal-infant outcomes? What is the psychoemotional toll on women who may be required to undergo an extremely invasive and personal procedure that is not medically indicated this should serve as a wake-up call for all women and a call to attention that healthcare providers cannot afford to ignore the political context in which they practice; moreover, they need to exercise all means at their disposal to advocate for the provision of high-quality, safe, accessible evidence-based care. This includes being informed voters, becoming actively involved in their professional associations, and engaging in ongoing dialog with candidates and elected officials. Clearly the public needs health education that nurses are well prepared to provide if those who are elected to offices of great civic responsibility can promulgate such egregious misinformation.

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