A decision to place more restrictions on medication abortion will not stop people from getting abortion pills—it will merely reshape, not extinguish, the landscape of access to abortion pills.
On Tuesday, March 26, the U.S. Supreme Court will hear a case on the abortion pill mifepristone that could see significant restrictions imposed on that medicine. The Supreme Court justices who overturned Roe v. Wade in 2022 claimed to return the issue to the states, where each state could make its own democratic decisions about abortion. Not so, it seems—for now the Court is entertaining nationwide restrictions on the most common abortion method: medication abortion.
The case, Food and Drug Administration v. Alliance for Hippocratic Medicine, was brought by a group of anti-abortion doctors to challenge the FDA’s approval of mifepristone. The Supreme Court will decide whether to keep the drug available, as it is now, or reinstate a set of restrictions on it. These restrictions would not ban medication abortion altogether, but they would impose limits that would make it harder to obtain, even in states with liberal abortion laws. Currently, 14 states ban medication abortion and 36 states allow it to varying degrees.
(Editor’s note: At-home abortions via medication abortion are safe and still available in all 50 states. The organization Plan C has a comprehensive guide to finding abortion pills on their website, which is continually updated and has all the latest information on where to find abortion pills from anywhere in the U.S.)
We need to look closely at activism on the ground to understand the reality of medication abortion and to see, ultimately, that anti-abortion rulings and laws do not stop people from getting abortions.
Mifepristone and misoprostol are the two drugs used in a medication abortion, the method that makes up the majority of abortions in the U.S. Medication abortion has been transformative for the safety and availability of abortion, especially where it is hard to access, resulting in a substantial drop in injury and death from unsafe abortion. It has been used around the world since the late 1980s and has been added to the essential medicines list by the World Health Organization.
After a decade of debate, mifepristone was approved by the FDA in 2000 for use seven weeks into pregnancy. This timing refers to seven weeks from the last menstrual period, which is approximately five weeks after conception. The FDA saddled mifepristone with extra restrictions on who could prescribe it and where it could be used, such as banning pharmacists from dispensing it and requiring patients to take multiple trips to the clinic to consume the pills.
After reviewing years of evidence on mifepristone’s safety, some of these restrictions were relaxed.
In 2016, the FDA changed its rules, allowing medication abortion to be used up to ten weeks into pregnancy and permitting the second set of medicines to be taken at home, rather than inside a clinic.
In 2021, during the pandemic, the rules changed again to allow medication abortion pills to be dispensed through the mail. These changes made it easier for people to access abortion pills; once pills could be prescribed and dispensed remotely, new telemedicine services like Hey Jane and Just the Pill emerged, sending abortion pills through the mail after a phone, text or video consultation with a doctor.
If the Supreme Court rules in favor of the anti-abortion doctors, and overturns the FDA’s current mifepristone regulations, the result would be a nationwide ban on medication abortion telemedicine services and mail-order dispensing. Little would change in states that already have abortion bans, but states where abortion is legally available would be forced to return to outdated rules that make it harder to access safe abortion.
However, as I demonstrate in my book Abortion Pills Go Global, focusing solely on court rulings and laws on medication abortion provides only a limited view of the broader context. We need to look closely at activism on the ground to understand the reality of medication abortion and to see, ultimately, that anti-abortion rulings and laws do not stop people from getting abortions. This is because abortion pills are widely available online through pharmacy sites and feminist activist networks. The pills are usually cheap to buy and relatively easy to ship internationally.
Countries that restrict abortion have seen their laws upended by the flow of pills.
- In Ireland, evidence about the availability of abortion pills through the mail persuaded politicians that their country’s abortion ban could not be enforced.
- In Northern Ireland, prosecutions of women who had used abortion pills and the people who helped them get the pills provoked public backlash, helping to change opinion and contributing to activist efforts to decriminalise abortion.
- In Poland, where a near-total abortion ban remains in place, the activist group Abortion Without Borders helped roughly 45,000 people to have abortions with pills during 2023.
Self-managed abortion with pills is also widespread in the U.S. and has been since well before Roe v. Wade was overturned. People turn to online pharmacies where they can buy abortion pills manufactured in India; these sites sell brands that are not FDA-approved but are chemically equivalent. People also turn to feminist activist groups like Aid Access who are now shipping FDA-approved medications from inside the U.S. directly to those in need. Abortion-seekers in the U.S. also use creative strategies to move pills across state borders when they live in states that ban telemedicine abortion.
Self-managed abortions are notoriously difficult to count, because people rightly fear attention from police and prosecutors—Americans have been jailed for using abortion pills or helping others to buy them. Nonetheless, recent studies demonstrate that there is greater demand for self-managed abortion in states with harsher abortion restrictions.
A decision to place more restrictions on medication abortion will not stop people from getting abortion pills. Just as anti-abortion laws in red states have led to an enormous increase in abortion travel across state borders, restrictions on medication abortion will simply change the way that people obtain pills. They will find pills through informal and illicit sources online if they can no longer obtain them through domestic telemedicine abortion services. Medication abortion has changed the geography of abortion and consequently made it easier for abortion seekers to circumvent anti-abortion laws.
Any Supreme Court decision to restrict mifepristone will not change this—it will merely reshape, not extinguish, the landscape of access to abortion pills.
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