Since the Supreme Court’s 2022 Dobbs ruling, state ballot initiatives have become a powerful tool used by advocates on both sides hoping to either protect or limit abortion access in their state. Successful ballot initiatives that enact state constitutional amendments provide stronger legal authority to either protect or restrict abortion than laws enacted by the legislature or state Supreme Court rulings. Since 2022, twelve states have passed ballot initiatives, usually, but not exclusively, to protect abortion rights in their state. Once again, this November, four states (Table 1) will have abortion-related measures for their voters to consider. Abortion rights advocates in Nevada and Virginia have placed a constitutional amendment protecting the right to abortion on the November ballot. The Missouri legislature has placed an initiative on the ballot to repeal a state constitutional amendment protecting the right to abortion approved by voters in 2024. In addition, voters in Idaho will decide on a state statute that would guarantee a right to abortion until fetal viability or after fetal viability when the patient experiences a medical emergency. This issue brief reviews the abortion-related initiatives on the ballot in November 2026 and examines how these measures may impact abortion access in the state. 

Ballot Initiatives Seeking to Protect Abortion Rights

Virginia

Virginia is currently the only state in the South that does not ban the provision of abortion or impose an early gestational limit, currently allowing abortion until the third trimester. Unless the litigation, described below, challenging the placement of the ballot measure succeeds, voters in Virginia will decide whether to enshrine these abortion protections into the state constitution in November. On February 6, 2026, Governor Spanberger signed a bill, placing the Right to Reproductive Freedom Amendment on the ballot, after the legislature passed it in two successive sessions, as is required by state law. However, on March 3, 2026, Charla Bansley, the District 3 Supervisor for the Bedford County Board of Supervisors, filed a lawsuit seeking to block the placement of the measure on the November ballot. Ms. Bansley alleges state election officials failed to distribute the constitutional amendment to circuit clerks in all counties, as required by state law, before certifying the abortion measure for the ballot.

On July 24, 2026, a district court judge issued an order dismissing Bansley’s lawsuit with prejudice because she failed to establish that she had standing to bring the lawsuit, and the operative law that Bansley attempted to rely on to challenge the ballot language had been repealed. On September 12, 2026, the Virginia Court of Appeals heard an appeal to Bansley’s lawsuit, challenging the ballot initiative placement on the November 2026 ballot. The Virginia Court of Appeals denied Bansley’s petition to bypass appellate review and go directly to the Virginia Supreme Court. Bansley’s opening brief is due October 19, 2026.

A separate lawsuit challenging the Right to Reproductive Freedom Amendment was filed on April 30, 2026, by two medical advocacy groups and by Meagan Kade, a member of the Bluefield town council. The Plaintiffs argue that the language of the ballot initiative does not accurately convey the legal impact of the new constitutional amendment to voters. Additionally, they make the same argument as Bansley that the amendment was not properly circulated. A hearing was held in June 2026. The case is still unresolved, and early voting for Virginia began on September 18, 2026.

The Right to Reproductive Freedom Amendment would amend the state constitution to guarantee a fundamental right to abortion until the third trimester, as well as contraception and fertility care. The Amendment would allow the Commonwealth of Virginia to regulate abortion in the third trimester; however, abortion cannot be prohibited if the pregnant person’s life or physical or mental health is at risk, or if the fetus is not viable. If passed, the Amendment will provide durable protection for abortion rights in the state’s constitution by ensuring that changes in the composition of the legislature or the courts in the Commonwealth do not impede access to abortion care.

Nevada

Nevada law requires citizen-initiated ballot initiatives amending the state’s constitution to pass in two successive general elections. Therefore, Nevadans will vote for the second time on the Reproductive Rights Amendment initially approved by voters in 2024. If passed, the Reproductive Rights Amendment will, “guarantee a right to all individuals to abortion performed or administered by a qualified health care practitioner until fetal viability or when needed to protect the life or health of the pregnant patient, without interference from the state or its political subdivisions.” 

Abortion is currently legal in Nevada until 24 weeks gestation. In 1990, voters passed as a “statute affirmation” which upheld the existing law, NRS 442.250, which legalized abortion until 24 weeks, and prohibited the state legislature from amending or repealing the law unless it was placed on the ballot. In 2019, Nevada enacted the Trust Nevada Women Act, which decriminalized medication abortion and removed informed consent laws. The Reproductive Rights Amendment would protect the individuals’ right to abortion beyond the existing law by limiting state interference. While passage of the Reproductive Rights Amendment would provide the strongest protection against efforts to limit reproductive rights by the legislature or courts, any effort to change the gestational limit for abortion in Nevada would have to be approved by a direct vote of state residents, not by the legislature. 

If the Reproductive Rights Amendment passes, abortion rights advocates are likely to bring a new challenge to Nevada’s parental notification for minors law, contending it is not permissible under the new constitutional amendment. If successful, this challenge would allow minors to consent for their own abortions. Last year, a lower court lifted a 1985 injunction blocking the notification law and reinstated the parental notification requirement. Planned Parenthood Mar Monte, the affiliate that operates the Nevada Planned Parenthood clinics, challenged the lower court's order, and the Nevada Supreme Court preliminarily enjoined the law.

Idaho

Idaho has among the most restrictive abortion laws in the nation. Abortion rights advocates are seeking to reverse these restrictions by trying to get a new law approved, the Reproductive Freedom and Privacy Act, which will change the legality of abortion in the state. Idaho is currently enforcing a total ban on the provision of abortion, with exceptions only to prevent the death of the pregnant person or in the first trimester for reported cases of rape or incest. The Reproductive Freedom and Privacy Act would create a state law giving people the right to make decisions about their own reproductive health care, including abortion up to fetal viability, and after fetal viability if the patient is experiencing a medical emergency, miscarriage care, prenatal, pregnancy, and postpartum care, contraception, and fertility treatment. However, the initiative faced considerable barriers to getting on the ballot. In Idaho, a citizen-initiated ballot initiative can only be placed on the ballot if the petitioner gathers signatures from 6% of the registered voters in the last election in 18 of the state’s 35 legislative districts and submits these signatures by May 1 of the election year. The signatures must then be verified by the county clerks and submitted to the secretary of state for certification. Idahoans United for Women and Families, a nonprofit group that advocates for comprehensive reproductive health care in the state, is organizing the 2026 ballot initiative. On July 13, 2026, the Idaho Secretary of State announced that Idahoans United for Women and Families had collected enough valid signatures for the initiative to qualify for the November 2026 ballot.

In addition to facing barriers to collecting signatures, Idahoans United has also filed multiple lawsuits against the attorney general’s office regarding the ballot language. In January 2025, the group sued the attorney general’s office, arguing that the financial impact statement and the short title of the ballot initiative contained biased language. On June 16, 2025, the Idaho Supreme Court agreed and ordered the attorney general to draft a new financial statement and short title. 

On August 27, 2026, Idahoans United for Women and Families filed another lawsuit against the Secretary of State and the Attorney General of Idaho, alleging that the drafted ballot language did not contain a clear and concise statement on the effect of a “YES” or “NO” vote. The original “NO” statement, as written by the Secretary of State and Attorney General, provided: "A NO vote would make no change to Idaho’s current law, which protects the life of the unborn while allowing abortion in reported cases of rape or incest, or when necessary to protect the life of the mother. Idahoans United alleged that the “NO” statement, as written, mischaracterized Idaho’s current abortion law, leading voters to believe that Idaho law “allow[s] abortion . . . when necessary to protect the life of the mother,” when the current law only allows abortions to prevent the death of a pregnant person, and used inaccurate and argumentative language such as “protects the life of the unborn.”

Additionally, Idahoans United argued that the “YES” statement similarly violated Idaho law because it was not a clear and concise statement that describes the legal effect of a “YES” vote. The original “YES” statement provided: “A YES vote would establish reproductive rights, including a right to abortion before a fetus's ability to survive and after a fetus's ability to survive in cases of a medical emergency, and provide liability protections for healthcare providers.” Idahoans United argued that the “YES” statement description of fetal viability could confuse voters because if the statement continued on the ballot as written, it would describe the same point in pregnancy (viability) four different ways: in the initiative text, in the short title, in the long title, and in the “YES” statement.

On September 4, 2026, the Idaho Supreme Court ordered the Secretary of State and the Attorney General to rewrite the ballot language after finding the original version failed to comply with state law by not clearly and concisely stating the effects of “YES” and “NO” votes.

If passed, the Reproductive Freedom and Privacy Act could expand access to abortion in Idaho. However, the Act would still face challenges after the election because Idaho allows its legislature to amend or repeal a citizen-initiated statute without restrictions. There are numerous examples where the legislature has reversed or amended the will of the electorate. In 2002, the Idaho legislature repealed citizen-initiated statutes that sought to place term-limits on elected officials. In 2019, the Idaho legislature amended a citizen-initiated statute that expanded Medicaid eligibility.

Ballot Initiatives Seeking to Curtail Abortion Rights 

Missouri 

In 2026, voters in Missouri will again be asked to decide the legal status of abortion in their state, but this time to reverse a recently approved constitutional amendment. In 2024, Missouri voters approved Amendment 3, the Right to Reproductive Freedom Amendment, which amended the state’s constitution to guarantee a right to abortion until fetal viability. Before Amendment 3 was passed, Missouri banned the provision of abortion with exceptions only to avert the death of the pregnant person or to avert a serious risk of substantial and irreversible physical impairment of a major bodily function of the pregnant person. After Amendment 3 passed, Planned Parenthood, one of the abortion providers in the state, filed a lawsuit challenging not only the state’s total abortion restriction, but also a series of regulations on facilities and clinicians providing abortions. These restrictions included a 72-hour waiting period between an initial appointment and when an abortion could be performed, and abortion specific informed consent requirements. In June 2026, the court permanently struck down some regulations on facilities and clinicians providing abortions; however, some regulations remain. The litigation is ongoing and is currently at the Missouri Supreme Court. The state's total abortion restriction had already been struck down.

State legislators who oppose abortion rights have drafted a new ballot initiative that seeks to repeal Amendment 3. The 2026 ballot initiative, also known as Amendment 3, would ban the provision of abortion except in cases of medical emergencies, fatal fetal anomalies, or pregnancies 12 weeks or less gestation that are a result of rape or incest. The initiative includes a parental or guardian consent requirement for minors except in medical emergencies and prohibits state funding of abortions in most circumstances. The ballot initiative explicitly allows the legislature to regulate abortion provision, facilities, and providers including, “requiring physicians providing abortion care to have admitting privileges at a nearby hospital; laws requiring facilities where abortions are performed or induced to be licensed and inspected for clean and safe conditions and adequate instruments to treat any emergencies arising from an abortion procedure; laws requiring physicians to perform a sufficient examination of the woman to determine the unborn child's gestational age and any preexisting medical conditions that may influence the procedure; and laws requiring ultrasounds to be performed only by physicians or licensed medical technicians.” In addition, the initiative includes a ban on gender affirming care for minors. 

The 2026 ballot initiative has faced legal scrutiny. On July 2, 2025, the ACLU of Missouri filed a lawsuit against the secretary of state, alleging that the language for the 2026 ballot initiative was intentionally misleading, contained an inaccurate summary, and is unconstitutional because it included more than one subject. The ACLU argued that the language of the ballot initiative failed to properly inform voters that a “yes” vote would lead to a repeal of reproductive rights protections that passed in 2024. The ACLU also contended that the subject of the ballot initiative is related to “reproductive health care,” but includes topics unrelated to reproductive health, including a ban on gender-affirming care for minors. On July 4, 2025, the Missouri Western District Court of Appeals ruled that the language of the 2026 ballot initiative failed to inform voters that the initiative would repeal and replace the 2024 Right to Reproductive Freedom Amendment, and certified new ballot language for the 2026 ballot initiative. The language certified by the court will appear on the November 3, 2026, ballot. This is the first time voters could decide to repeal a state constitutional amendment protecting abortion. Passage of the 2026 ballot initiative would ban the provision of abortion in Missouri and prevent minors from accessing gender affirming care. 

Some Abortion Restrictions Remain in Place After Voters Pass Constitutional Amendments

Voters in Arizona, Ohio, and Missouri passed state constitutional amendments establishing the right to abortion in recent elections. After abortion advocates challenged existing state restrictions on the provision of abortion under the new constitutional amendments, courts have blocked the pre-existing state abortion restrictions. However, legal challenges to existing abortion restrictions such as waiting periods and telemedicine restrictions, have taken longer as courts have not uniformly blocked these provisions. 

On November 5, 2024, Arizona voters passed Proposition 139, a ballot initiative that amended the state constitution to guarantee a right to abortion until fetal viability. The amendment also allows abortions after fetal viability if the physician providing the abortion determines that the abortion is necessary to protect the life or physical or mental health of the pregnant person. After this constitutional amendment became effective in December 2024, advocates filed legal challenges to block Arizona’s 15-week ban on the provision of abortion and other abortion restrictions. In March 2025, a court ruled Arizona’s 15-week ban was unconstitutional under the new amendment. In February 2026, an Arizona state court ruling blocked several abortion restrictions, including: (1) a ban on abortion based on fetal diagnoses; (2) a 24-hour waiting period and (3) a prohibition on telemedicine for abortion care due to new protections granted in the state’s constitutional amendment. However, Republican state legislators who have intervened in the lawsuit may appeal this decision. The Democratic Arizona Attorney General declined to defend the laws on behalf of the state, and therefore it is unlikely the state will appeal. 

There are, however, still abortion restrictions in effect in Arizona, including a ban on state funds for abortion (which affects Medicaid), a parental consent requirement for minors seeking abortions, and a law that bars medical professionals other than doctors from providing abortions. In February 2026, the ACLU of Arizona filed a lawsuit on behalf of advanced practice clinicians, contending the physician-only law violates the constitutional amendment protecting abortion. 

On November 7, 2023, Ohio voters passed Issue 1, a ballot initiative that amended the state constitution to guarantee every individual has the right to make their own reproductive decisions, including contraception, fertility treatment, continuing a pregnancy, miscarriage care, and abortion care. The amendment also allows the state to prohibit abortion after fetal viability; however, an abortion cannot be prohibited after viability if it is necessary to protect the life or health of the pregnant person. After the passage of Issue 1, advocates cited the new amendment in legal challenges to the state’s 6-week ban on the provision of abortion as well as the many other abortion restrictions. In October 2024, the Hamilton County Court of Common Pleas issued a permanent injunction blocking Ohio’s 6-week abortion ban from taking effect, marking the first permanent injunction based on Ohio’s Reproductive Freedom Amendment. Courts have blocked many of the other abortion restrictions as well. One provision that was challenged, but is still in effect, is a requirement for providers to document the reason for an abortion, but this provision does not impact patients’ access to abortion care. Ohio law still requires parental consent for minors seeking abortions and blocks public funding for abortions. 

As was discussed earlier, Missouri voters approved Amendment 3, the Right to Reproductive Freedom Amendment, in 2024, which guarantees a right to make and carry out decisions about all matters relating to reproductive health care, including: prenatal care, childbirth, postpartum care, birth control, abortion care, miscarriage care, and respectful birthing conditions. The amendment also allows the government to regulate abortion after fetal viability; however, it prevents the government from restricting abortion after fetal viability if the abortion is necessary to protect the life, physical or mental health of the pregnant person. After the passage of Amendment 3, a court blocked the state’s ban on the provision of abortion, as well as most of the restrictions, including a 72-hour waiting period and abortion specific informed consent requirements. However, the litigation is ongoing and is currently at the Missouri Supreme Court.  

Options for Future Citizen-Referred Ballot Measures Are Limited

Citizens are allowed to propose a constitutional amendment for the ballot in 17 states. There are only two states, Arkansas and Oklahoma, with current bans on the provision of abortion which allow for citizen-initiated constitutional amendments and have yet to vote on an abortion measure (Figure 1). There were efforts in Arkansas (where there is a near-total ban on the provision of abortion) to get an initiative on the ballot, but the Arkansas Secretary of State rejected the petition for the initiative because the signatures were not properly gathered, and thus the initiative did not make it to the ballot. The Arkansas Supreme Court upheld this decision. 

Oklahoma has a total ban on the provision of abortion, with an exception only to save the life of the pregnant person, and classifies performing an abortion as a felony. A citizen-led effort to put a state constitutional amendment that would have added an “individual right to reproductive freedom” on the ballot was withdrawn in December 2022, before signature gathering began.

In 2024, in Florida, Nebraska, and South Dakota, abortion rights amendments failed to garner sufficient votes for passage. In Nebraska, voters approved a competing measure to ban the provision of abortion after the first trimester. In South Dakota, the measure failed to pass, only garnering 41% of the votes. In Florida, the initiative received 57% approval. However, state law requires 60% approval for a constitutional amendment. As the popular vote fell just 3 percentage points short of approval, abortion rights supporters in Florida may try again in a future election to reverse the 6-week ban on the provision of abortion. 

Conversely, in states with current abortion protections without a constitutional amendment protecting abortion, only three states (Illinois, Massachusetts, Oregon) have a process for citizen-initiated constitutional amendments. However, in today’s political climate, it is unlikely that new citizen initiatives will be brought to the electorate to weaken existing abortion protections.

In this column for Nature, KFF’s Alina Salganicoff reviews efforts to improve women’s health research during previous U.S. administrations that fell short of their promise and highlights the recommendations of a congressionally mandated National Academy of Sciences, Engineering and Medicine committee, which she co-chaired, aimed at improving women’s health research at the National Institutes of Health.