By Rachel Crumpler

Neha Kar, a 23-year-old from Morrisville, woke up at 2:45 a.m. to board a bus to Washington, D.C., on Tuesday. 

She had other things she could have been doing, but spending 10 hours going to and from D.C. on this day was important to her. She wanted to be outside the U.S. Supreme Court as the justices heard oral arguments in a case that could affect access to a medication abortion pill — mifepristone — used in about two-thirds of abortions nationwide. 

Kar said access to abortion weighs heavily on her mind these days, particularly since the same Supreme Court overturned five decades of precedent when it struck down Roe v. Wade in June 2022, and states subsequently moved to restrict abortion access. That includes her home state, North Carolina, which last summer banned most abortions after 12 weeks of pregnancy.

“Bodily autonomy is one of the most important rights that we have,” Kar said. “I don’t believe that anyone should choose what happens to my body, except for me and whoever else I allow, such as my doctor.”

And now that she’s in her reproductive years, Kar is worried and frustrated that she has less access to abortion if she should one day need it.

“It’s difficult to know that people are pushing for us to go backward — that a right I had for much of my life has been taken away when I’m of reproductive age now,” Kar said.

About 70 other North Carolinians made the journey to D.C. in support of abortion access, said Jillian Riley, Planned Parenthood’s North Carolina director of public affairs, who helped organize the buses from Raleigh and Chapel Hill.

For Pat Adams, who made the trip from Chapel Hill, it wasn’t her first trip to D.C. in support of abortion access. She’s been advocating for access to abortion care for decades — even before Roe. 

And at age 31, Adams had an abortion. She said she was in a marriage that she knew would not last and would be in a bad situation with a child.

“Very personal, deep thought went into that decision,” Adams said. “We made the right decision when we had the abortion.”

And she wants others who need access to abortion to continue to have it, so she said that means she will keep coming to D.C. to “keep fighting back because this is a right.”

When Adams and Kar arrived in the nation’s capital, they joined a loud, bustling scene outside the steps of the Supreme Court. Supporters of abortion access were visible, dressed in bright pink and wielding signs like “I’m pro-choice and supremely pissed off,” “Everyone deserves the power to decide” and “Abortion on our own terms.”

There were frequent chants of “2,4,6,8, abortion pills in every state,” “We will not go back” and “Dismiss this case on its face.”

Just feet away, supporters in favor of restricting access to mifepristone gathered with their own signs reading “FDA: do your job” and “Women’s health matters.” Many wore white coats. Tammy Fitzgerald, head of the NC Values Coalition and a staunch abortion opponent, was in attendance. Her organization had organized a rally to encourage the court to rule with the plaintiffs. 

People of all ages on both sides of the abortion debate stayed to make their perspectives known during the duration of the Supreme Court oral arguments that started at 10 a.m. — with some of the noise even permeating into the courtroom. 

There was a palpable energy outside the court, as all involved seemed to know the stakes of the case — the first abortion case since this same Supreme Court overturned Roe v. Wade.

Medication abortion use has evolved

The Supreme Court heard 90 minutes of oral arguments in FDA v. Alliance for Hippocratic Medicine Tuesday morning over whether to restrict access to mifepristone, one of two medications commonly used to induce an abortion. The Supreme Court took the case after conflicting lower court rulings that had the potential to restrict access to the medication. The Supreme Court enjoined those decisions until its own justices had an opportunity to issue a ruling.

The FDA first approved mifepristone in 2000. Since then, roughly 6 million patients have taken the medication, according to the FDA.

Over the years, the FDA has studied and reaffirmed mifepristone’s safety and subsequently eased restrictions on how the medication can be dispensed. In 2016, the FDA expanded usage from up to seven weeks after a person’s last menstrual period to 10 weeks. The agency also allowed certified health care practitioners, such as nurse practitioners and physician assistants, to dispense the medication. 

In 2021, the FDA again loosened restrictions on the medication by eliminating any in-person requirements and allowing the pill to be sent through the mail.

These changes have made medication abortion more accessible, said Amy Friedrick-Karnik, director of federal policy at the Guttmacher Institute. And, in part, that’s contributed to a rise in medication abortions.

About 642,700 medication abortions were provided in the United States in 2023, accounting for 63 percent of all abortions in the formal health care system, according to data released last week by Guttmacher. This marks an increase from 2020 when medication abortions accounted for 53 percent of all abortions. These numbers do not account for self-managed abortions or abortion medication ordered by and mailed to people in states with total bans.

In particular, abortion by telemedicine has opened access for a large segment of the population. Data released by the Society of Family Planning in February revealed that abortions provided through telehealth make up about 16 percent of all abortion care nationwide. 

Dana Northcraft, founding director of Reproductive Health Initiative for Telehealth Equity & Solutions, said telehealth has been a linchpin of access amid state bans on abortion and clinic closures in states with new bans. Northcraft helped launch telehealth abortion at Planned Parenthood affiliates across the country and said the responses have been positive. 

“One particular person I’m thinking about said she felt much safer and much, much more cared for because she was able to stay in her own community and get the care that she needed, rather than having to travel a long distance to get there,” Northcraft said.

But the Supreme Court will be determining whether the FDA erred when loosening restrictions on how mifepristone can be dispensed, having the potential to cut these new options.

During the arguments, the justices appeared likely to preserve access to the drug, with liberal and conservative justices voicing skepticism over the lawsuit’s scope.

“We have before us a handful of individuals who have asserted a conscience objection. Normally, we would allow an equitable relief to address them,” Justice Neil Gorsuch said. “This case seems like a prime example of turning what could be a small lawsuit into a nationwide legislative assembly on an FDA rule or any other federal government action.”

Already in a world beyond any ruling

North Carolina never felt the loosening of restrictions on mifepristone access felt by people in many other states. That’s because North Carolina is one of the most restrictive states for medication abortion access; its state law adds restrictions beyond the FDA’s usage rules.

In North Carolina, medication abortion pills must be dispensed in person by a physician following a 72-hour waiting period after state-mandated counseling. Due to these rules, telehealth is not an option.

These additional restrictions upset doctors providing abortion care in North Carolina who say they are medically unnecessary. 

Katherine Farris, chief medical officer at Planned Parenthood South Atlantic, occupies a unique position that lets her see just how disparate the rules are from state to state. 

When her feet are planted in Virginia, she can offer patients care through telehealth. It’s an option patients like to have, she said, and can be done on their own timeline — even a lunch break.

“They answer all the questions, they get the counseling, they go through the consent process and then the pills are mailed to them,” Farris explained. “And then after work, they can take the pills as soon as they come — the next day — so they can miss literally not an hour of work. They don’t need to get even a minute of child care. They don’t need gas money. They don’t need time to travel. They don’t need to borrow anyone’s car. They can just get the care they need where they are. And that is what health care should be.”

Studies show that abortion provided through telehealth is as safe as in-person care. The latest study published February in Nature Medicine shows that telehealth for medication abortion is safe and effective whether the patient uses a secure form of texting or a video call. Of the 6,034 abortions in the study, 99.8 percent were not followed by a serious adverse event.

But that’s not an option for providers in North Carolina. The minimum two-appointment in-person process for medication abortion is a barrier some patients can’t overcome. Farris said about 10 percent of patients who come in for the first counseling appointment don’t make it back for the second appointment.

Farris added that there is “unequivocally” no difference in safety or outcomes between patients in Virginia and North Carolina. But she said she’s hearing of more patients who are going outside of the formal health care system. 

“I don’t have any problem with a patient who chooses to not engage with a formal health care system,” Farris said. “What I have a problem with is when the state writes a law that essentially pushes patients into doing that and makes it so hard for them to get care from a formal health care provider that they’re then forced to go outside of that system in order to get the care they need.”

Amy Bryant, an abortion provider in North Carolina, filed a lawsuit in January 2023 challenging the state’s additional requirements on medication abortion. The case is awaiting summary judgment.

“It makes it just harder for people to have to jump through these extra hoops,” Bryant said. “It doesn’t make any sense, and it makes it so that we can’t prescribe medication abortion like our counterparts in other parts of the country. And I think that that’s not fair and doesn’t provide for optimal care for patients.”

North Carolina state Rep. Julie von Haefen (D-Raleigh), who attended and spoke at the rally outside the Supreme Court, told NC Health News it was important to tell those gathered about the harms of restricting the availability of abortion through telehealth.

“We’ve seen firsthand how it’s affected people in our state,” von Haefen said. “I don’t want to see this happen across the country because we know how devastating it can be for patients.”

She’s filed a bill trying to remove the restriction on telehealth the past two legislative sessions, but she said it hasn’t gone anywhere with Republican lawmakers.

Despite these additional requirements, medication abortion accounts for nearly 70 percent of total resident abortions in North Carolina, according to the latest state data, with 19,967 medication abortions being provided in 2022. 

Bryant explained that the method is prevalent because patients often perceive it as more convenient and natural because it can feel more like a miscarriage and there may be less clinic capacity for procedural abortion.

Months until a decision

While the skepticism expressed by the justices during oral arguments seems to indicate that they are reluctant to reinstate past restrictions on mifepristone, those on both sides will have to wait until the decision, expected in June, to see if another change upends abortion access. 

A decision that rolls back FDA approval would have less of an impact on North Carolina, but advocates warn any change to access would have ripple effects that affect care across the nation.

Until then, Friedrick-Karnik from Guttmacher said people are working to navigate the bans any way they can. The organization found that 2023 saw the largest number of abortions in a decade, even with new state bans in effect.

“People are doing what they need to get the abortion health care,” Friedrick-Karnik said. “They're overcoming great barriers to travel. They are using telemedicine when it's available.”

“I’m certain we will see an impact, particularly if patients have to go into a clinic regardless of the state they are in,” said Planned Parenthood South Atlantic’s Jillian Riley. “I’m telling you right now our health centers are already working double time in order to meet demand for abortion care in our state.”

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