Authors: Rhea Manohar, MPH; Leah Liszak, Sarv Raafati, Laura Andreson, MD on behalf of the Gender Equity Task Force

Read the Statement from the Reproductive Health Coalition on Mifepristone Access here: https://www.doctorsforamerica.org/news/statement-release-reproductive-health-coalition-on-mifepristone-access

In May 2026, medication abortion once again became the focus of a national legal battle after the Fifth Circuit Court of Appeals allowed the restrictions on mailing mifepristone to move forward in a case brought by the state of Louisiana against the FDA in October 2025 (Sherman & Mulvihill, 2026; Sobel et al., 2026). The ruling threatened to reinstate mandating in-person physician visits to obtain mifepristone, effectively restricting telehealth prescribing, pharmacy dispensing, and mail distribution nationwide after the FDA permanently permitted access in December 2021 (Sherman & Mulvihill, 2026; Sobel et al., 2026). 

The implications were immediate. Since the FDA’s 2021 ruling, patients had been able to receive mifepristone through telehealth appointments and certified pharmacies without an in-person visit, a shift that substantially expanded reproductive healthcare access after the overturning of Roe v. Wade (Sherman & Mulvihill, 2026; Sobel et al., 2026). Post this overturning, medication abortion rapidly became one of the primary ways patients accessed abortion care in the United States, particularly in states with increasing procedural restrictions (Sherman & Mulvihill, 2026; Sobel et al., 2026). 

Just days after the Fifth Circuit ruling, the Supreme Court of the United States temporarily restored access to mifepristone through telehealth, mail delivery, and pharmacies while litigation proceeds, which was confirmed by the Supreme Court hearing on May 15th, 2026 (Sherman & Mulvihill, 2026; Sobel et al., 2026). While the Court’s decision maintained the status quo, the broader legal uncertainty surrounding medication abortion remains unresolved (Sherman & Mulvihill, 2026; Sobel et al., 2026). The case reflects a growing conflict between evidence-based reproductive healthcare and politically motivated restrictions that continue to reshape abortion access and reproductive health equity across the country.

At the center of this legal dispute is mifepristone, a medication with more than two decades of clinical use and an extensively studied safety profile (Sherman & Mulvihill, 2026; Sobel et al., 2026). By 2023, medication abortion accounted for approximately 63% of all abortions in the United States compared to 53% prior to 2020 (Ralph et al., 2024). Despite this widespread use, public discourse surrounding mifepristone often remains disconnected from the medical evidence itself.

Mifepristone is a selective progesterone receptor modulator that functions primarily as an antiprogestin (Committee on Practice Bulletins—Gynecology Society of Family Planning, 2020; Institute of Medicine (US) Committee on Antiprogestins, 1993). Progesterone is essential for maintaining pregnancy, and mifepristone competitively binds to progesterone receptors with approximately five times greater affinity than progesterone itself without activating the receptor (Committee on Practice Bulletins—Gynecology Society of Family Planning, 2020; Institute of Medicine (US) Committee on Antiprogestins, 1993). This interruption initiates a coordinated physiologic process resulting in the termination of pregnancy.

The FDA-approved regimen consists of 200 mg oral mifepristone followed 24 to 48 hours later by 800 μg buccal misoprostol for termination of intrauterine pregnancy through 70 days’ gestation (Jones & Boonstra, 2024). Evidence further supports safety and efficacy through 77 days’ gestation, with an additional dose of misoprostol improving effectiveness later in pregnancy (Jung et al., 2023; MacNaughton et al., 2021). The combined mifepristone-misoprostol regimen remains significantly more effective than misoprostol alone and is considered the preferred evidence-based approach by the American College of Obstetricians and Gynecologists (ACOG; Committee on Practice Bulletins—Gynecology Society of Family Planning, 2020).

Importantly, the safety profile of medication abortion is exceptionally well established. Serious adverse events occur in fewer than 0.5% of cases, while overall effectiveness ranges from approximately 95% to 98% (Ralph et al., 2024). Expected side effects such as cramping, heavy vaginal bleeding, nausea, fever, chills, vomiting, diarrhea, weakness, headache, and dizziness are largely attributable to misoprostol and are typically self-limited (Jones & Boonstra, 2024). Severe complications remain rare, with emergency intervention for excessive bleeding occurring in fewer than 1% of patients and blood transfusion required in less than or equal to 0.1% of cases (Committee on Practice Bulletins—Gynecology Society of Family Planning, 2020; Jones & Boonstra, 2024). 

Contraindications to medication abortion remain narrow and well characterized, including suspected ectopic pregnancy, chronic adrenal failure, long-term corticosteroid use, hemorrhagic disorders or anticoagulation, inherited porphyrias, allergy to mifepristone or misoprostol, and the presence of an intrauterine device prior to removal (Jones & Boonstra, 2024; MacNaughton et al., 2021). These are standard clinical screening considerations routinely evaluated in reproductive healthcare settings.

ACOG guidance consistently reinforces that medication abortion is safe, effective, and appropriate for outpatient and telehealth care (Committee on Practice Bulletins—Gynecology Society of Family Planning, 2020). The organization specifically states that home administration of both medications is safe and effective, routine in-person follow-up is unnecessary for most patients, and telehealth provision demonstrates comparable safety and efficacy to in-person care (Committee on Practice Bulletins—Gynecology Society of Family Planning, 2020; Ralph et al., 2024) ACOG has additionally criticized REMS restrictions surrounding mifepristone, stating that these requirements “do not make the care safer, are not based on medical evidence or need, and create barriers to clinician and patient access” (Committee on Practice Bulletins—Gynecology Society of Family Planning, 2020).

International data similarly challenge the premise that increased restrictions improve patient safety. A population-level interrupted time-series study from Canada found that removing risk evaluation and mitigation strategies (REMS) like restrictions and allowing routine prescribing of mifepristone did not compromise abortion safety outcomes even as medication abortion utilization rose dramatically from 2% to more than 30% nationally (Schummers et al., 2022). Instead, broader prescribing access improved healthcare accessibility without increasing complications.

The consequences of restricting mifepristone access have become increasingly visible in the post-Dobbs era. As of mid-2025, 12 U.S. states had enacted total abortion bans while 29 others imposed severe restrictions (Anderson et al., 2025). In the six months following Dobbs, researchers estimated approximately 26,000 additional self-managed medication abortions occurred outside the formal healthcare system compared with pre-Dobbs levels (Aiken et al., 2024). While self-managed medication abortion itself remains highly effective and generally safe, patients in restrictive states frequently face legal uncertainty, delayed care, and difficulty accessing follow-up services (Aiken et al., 2024). 

Restrictions on mifepristone also force patients toward less effective alternatives. Misoprostol-only regimens, while clinically useful when necessary, demonstrate lower complete abortion rates of approximately 80% to 93% compared with roughly 95% to 98% for the combined regimen (Zhang et al., 2022; Jayaweera et al., 2023). This difference is clinically meaningful. Lower efficacy translates into more patients experiencing prolonged symptoms, requiring follow-up procedures, or facing ongoing pregnancies (Committee on Practice Bulletins—Gynecology Society of Family Planning, 2020).

The practical impact of mailing restrictions extends far beyond the courtroom. Telehealth provision of medication abortion has become a critical mechanism for patients in rural communities, individuals without reliable transportation, minors, patients facing intimate partner violence, and those unable to take time away from work or childcare obligations (Aiken et al., 2024; Jung et al., 2023; Ralph et al., 2024). Studies examining telemedicine abortion services consistently demonstrate comparable effectiveness to in-person care while improving privacy, convenience, and healthcare access, particularly for patients in medically underserved regions (Aiken et al., 2024; Jung et al., 2023; Ralph et al., 2024). 

For many patients, mailing access to mifepristone is not simply a matter of convenience. It represents the difference between obtaining timely reproductive healthcare and being unable to access care at all. In states with abortion bans, telehealth medication abortion and interstate prescribing networks have partially mitigated some of the geographic barriers created after Dobbs (Aiken et al., 2024; Jung et al., 2023; Ralph et al., 2024). Restricting mailing access threatens one of the few remaining pathways through which equitable reproductive healthcare can still be delivered across state lines.

The legal battle over mifepristone ultimately reflects a broader tension between medical evidence and political intervention in healthcare, specifically in achieving reproductive healthcare equity and autonomy. Decades of research, FDA review, international safety data, and guidance from leading medical organizations consistently demonstrate that medication abortion is safe, effective, and appropriate for telehealth distribution (Aiken et al., 2024; Jung et al., 2023). Yet despite this evidence, access remains vulnerable to shifting legal and political decisions rather than scientific consensus.

As courts continue determining the future of medication abortion in the United States, evidence-based medicine must remain central to policy discussions. Equitable access to reproductive healthcare, including medication abortion, is not solely a legal issue but a public health imperative grounded in patient autonomy, healthcare accessibility, and scientific evidence. 

References 

  1. Aiken, A. R. A., Wells, E. S., Gomperts, R., & Scott, J. G. (2024). Provision of Medications for Self-Managed Abortion Before and After the Dobbs v Jackson Women’s Health Organization Decision. JAMA, 331(18), 1558–1564. https://doi.org/10.1001/jama.2024.4266 
  2. Anderson, D. J., Bearak, J. M., Grimstad, F. W., Palanee-Phillips, T., & van der Straten, A. (2025). Biomedical innovations in contraception: gaps, obstacles, and solutions for sexual and reproductive health. Lancet (London, England), 406(10515), 2119–2132. https://doi.org/10.1016/S0140-6736(25)01187-0 
  3. Committee on Practice Bulletins—Gynecology Society of Family Planning. (2020, October). Medication abortion up to 70 days of gestation: ACOG Practice Bulletin, Number 225. Obstetrics & Gynecology. https://journals.lww.com/greenjournal/fulltext/2020/10000/medication_abortion_up_to_70_days_of_gestation_.43.aspx  
  4. Institute of Medicine (US) Committee on Antiprogestins: Assessing the Science; Donaldson MS, Dorflinger L, Brown SS, et al., editors. Clinical Applications of Mifepristone (RU 486) and Other Antiprogestins: Assessing the Science and Recommending a Research Agenda. Washington (DC): National Academies Press (US); 1993. 5, Antiglucocorticoid Effects of Antiprogestins. Available from: https://www.ncbi.nlm.nih.gov/books/NBK236375/ 
  5. Jayaweera, R., Egwuatu, I., Nmezi, S., Kristianingrum, I. A., Zurbriggen, R., Grosso, B., Bercu, C., Gerdts, C., & Moseson, H. (2023). Medication Abortion Safety and Effectiveness With Misoprostol Alone. JAMA network open, 6(10), e2340042. https://doi.org/10.1001/jamanetworkopen.2023.40042 
  6. Jones, R. K., & Boonstra, H. D. (2024, July 9). The Public Health Implications of the FDA update to the medication abortion label. Guttmacher Institute. https://www.guttmacher.org/article/2016/06/public-health-implications-fda-update-medication-abortion-label 
  7. MacNaughton, H., Nothnagle, M., & Early, J. (2021, April 15). Mifepristone and Misoprostol for early pregnancy loss and medication abortion. American Family Physician. https://www.aafp.org/pubs/afp/issues/2021/0415/p473.html 
  8. Ralph, L. J., Baba, C. F., Biggs, M. A., McNicholas, C., Hagstrom Miller, A., & Grossman, D. (2024). Comparison of No-Test Telehealth and In-Person Medication Abortion. JAMA, 332(11), 898–905. https://doi.org/10.1001/jama.2024.10680 
  9. Schummers, L., Darling, E. K., Dunn, S., McGrail, K., Gayowsky, A., Law, M. R., Laba, T. L., Kaczorowski, J., & Norman, W. V. (2022). Abortion Safety and Use with Normally Prescribed Mifepristone in Canada. The New England journal of medicine, 386(1), 57–67. https://doi.org/10.1056/NEJMsa2109779 
  10. Sherman, M., & Mulvihill, G. (2026, May 4). Supreme Court temporarily restores access to abortion pill mifepristone through telehealth, mail and Pharmacies. PBS. https://www.pbs.org/newshour/politics/supreme-court-temporarily-restores-access-to-abortion-pill-mifepristone-through-telehealth-mail-and-pharmacies 
  11. Sobel, L., Salganicoff, A., & Donelson, R. (2026, May 6). Louisiana v. FDA: Access to mifepristone back at the Supreme Court. Kaiser Family Foundation. https://www.kff.org/womens-health-policy/louisiana-v-fda-access-to-mifepristone-back-at-the-supreme-court/ 
  12. Zhang, J., Zhou, K., Shan, D., & Luo, X. (2022, May 24). Medical methods for first trimester abortion – zhang, J – 2022: Cochrane Library. Cochrane Database of Systematic Reviews. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002855.pub5/abstract?cookiesEnabled= 

About the Authors

Rhea Manohar, MPH, MS3

Rhea Manohar is a third year medical student from St. George’s University. She has a Masters in Public Health with a concentration in Maternal and Child Health from George Washington University Milken Institute of Public Health and a Bachelors of Science in Microbiology & Immunology, and Public Health from the University of Miami. She served as Co-VP of OB/GYN Education for St. George’s University’s Women in Medicine chapter in St. George, Grenada where she developed hands-on workshops to further reproductive health issues and navigating challenging physician-patient communication scenarios. Prior to medical school, she was a Research Associate for Fors Marsh Group, where she led qualitative and quantitative public health research and campaign development for federal agencies (e.g., CDC, NIH, DHHS, CPSC). She is also Medical Student Chair of the Gender Equity Task Force and a member of other working groups of the American Medical Women’s Association. When she is not pursuing medicine, you can find her reading, exploring artistic passions, and spending time connecting with friends and family.

Leah Liszak, MS3

Leah Liszak is a third-year M.D. candidate at St. George’s University. Originally from the northern suburbs of Detroit, she graduated cum laude from Oakland University in 2022, where she studied Biomedical Sciences. She served as the SMILEs Orphanage Home Coordinator for the St. George’s University Humanism Service Organization in St. George, Grenada, where she fostered impactful relationships with at-risk female youth and developed seminars to support their personal growth. She is also a member of the Gender Equity Task Force with the American Medical Women’s Association. Through both her extracurricular involvement and academic pursuits, she is passionate about building a career in Obstetrics and Gynecology that advances equitable reproductive health care.

Sarv Raafati MS3

Sarv Raafati is a third year medical student at St. George’s University. She completed her undergraduate at the University of Utah with a Bachelor of Science in Biomedical Engineering and a minor in Middle East Studies. She also holds a ​Bachelor of Medical Science from Northumbria University in England. During her time at SGU she was the lesson coordinator in STEMM, an organization committed to providing lessons to local classrooms in Science, Technology, Engineering, Math, and Medicine. When not focusing on medicine she can be found at your local rock climbing gym, reading, skiing, or just randomly exploring to find the best coffee shop to study. 

Laura Andreson, MD

Laura Andreson attended Des Moines University Medical School and completed her Obstetrics and Gynecology residency at the University of MN. She has practiced in MN, ND and now TN, and recently transferred from private practice to a laborist/hospitalist. She is a member of ACOG, AMA, and AMWA. She currently serves on the board of trustees for the Tennessee Medical Association. She is a fierce advocate for the women and families of TN at our state capitol and is currently running for the TN State House of Representatives.