Nearly 1 in 5 abortions happen through telehealth services in the United States. As part of those services, most clinicians provide medication abortions through 11 weeks of pregnancy, seeing patients via video, phone or text before mailing medications. But an upcoming Supreme Court ruling could put a stop to telehealth abortion services nationally, even in states like California.

This week, the Supreme Court begins hearing arguments in Food and Drug Administration v. Alliance for Hippocratic Medicine, a case that challenges the FDA’s suggested prescribing recommendations for mifepristone – one of two drugs commonly used in abortion care, alongside misoprostol. The judgment is expected in June and would only impact mifepristone use.

The case comes on the heels of the largest U.S. study on the safety of telehealth abortion services. UC San Francisco Professor Ushma Upadhyay, PhD, MPH, and colleagues researched the medical records of more than 6,000 patients and confirmed telehealth abortions are just as safe and effective as those done in person.

Upadhyay, who is also a public health scientist with the university’s Advancing New Standards in Reproductive Health (ANSIRH) research program, tells UCSF News what you should know about the case and what it could mean for abortion access.

How do mifepristone and misoprostol work?

Mifepristone blocks the hormone progesterone needed for pregnancy. When used in medication abortions, mifepristone stops the pregnancy. It also triggers the separation of the uterine lining, where a fertilized egg embeds.

A second medication, misoprostol, then allows the uterus to start contracting, expelling that lining and the pregnancy.

Is mifepristone safe?

Yes. Mifepristone has been used safely and effectively in the U.S. by more than 5 million pregnant people during the past 23 years. Today, two-thirds of all U.S. abortions involve mifepristone.

How has mifepristone’s use changed over time?

The FDA approved mifepristone for abortion in 2000, after a rigorous review of safety and efficacy data. The FDA changed its prescribing guidelines in 2016 and 2021 to update practices in line with the best scientific evidence.

In 2016, the FDA lowered the recommended dosage needed for medication abortion and extended the suggested use of mifepristone from seven weeks through 10 weeks of pregnancy. It also began allowing clinicians other than doctors to prescribe it, like nurse practitioners and physician assistants.

Then, during the COVID-19 pandemic in 2021, the Biden administration temporarily removed mifepristone’s in-person dispensing requirement to help reduce COVID-19 infections by keeping healthy people out of clinics and hospitals if they didn't need to be there. This opened the door for telemedicine abortions.

Two years later, in 2023, the FDA permanently removed the in-person dispensing requirement after reviewing data showing virtual prescribing was safe.

Source: Expanding Medication Abortion Access (EMAA)

Source: Expanding Medication Abortion Access (EMAA)

Why is the Supreme Court talking about mifepristone now?

In 2022, an organization called Alliance for Hippocratic Medicine filed a lawsuit in Texas claiming that mifepristone was unsafe and that the FDA had acted improperly by approving its use in 2000. The U.S. Department of Justice appealed the verdict to the U.S. Court of Appeals for the Fifth Circuit, which ruled that the original 2000 FDA approval was okay, but challenged the 2016 and 2021 changes to mifepristone prescribing.

The Supreme Court will now determine, in part, whether the FDA’s guidance on prescribing mifepristone will be rolled back to the 2000 guidance. If so, this would limit when people can access it and who can prescribe it. It could also ban telehealth abortions in all 50 states.

Why would prohibiting telehealth abortion matter?

Telehealth is a pillar in abortion services.

In one of our studies, 43% of about 1,600 people surveyed said they would not have had access to a timely abortion without telemedicine. This includes 2% of patients who reported they would have had to carry their pregnancy to term if these services were not available.

That study was done before the Supreme Court’s 2022 Dobbs decision, which removed federal protections for abortion services. We know that even more people are relying on telehealth abortions now, especially in states with abortion bans.

What could abortion care look like if the Supreme Court turns back the clock on mifepristone, limiting its use to earlier in pregnancy?

It could limit mifepristone’s use to the first seven weeks of pregnancy, especially in states where abortion is highly restricted.

In less restrictive states, the way clincians prescribe mifepristone probably won’t change much.

U.S. Abortion Policies and Access After Dobbs

Source: Guttmacher Institute

U.S. Abortion Policies and Access After Dobbs

Source: Guttmacher Institute


What happens when people can’t access abortions?

People may pursue unsafe abortions, which are a leading cause of maternal mortality globally.

And being refused an abortion can have other dire consequences even years later. UCSF’s landmark Turnaway Study followed 1,000 women for five years after they sought abortions. The study found that women who were denied terminations were more likely to be living in poverty, in poorer health and in abusive relationships than women who successfully accessed abortions.

If the Supreme Court restricts access to mifepristone, can misoprostol be used alone?

Yes, but there’s a catch. Misoprostol alone is very safe and very effective, but it is slightly less effective when used without mifepristone – and clinicians may need to prescribe more misoprostol to complete the abortion. Remember, mifepristone helps the body begin to separate the uterus’s lining from the uterus itself. Misoprostol helps the uterine begin contracting to expel that lining and the pregnancy.

Without mifepristone’s help in getting the process started, clinicians may have to increase the dose of misoprostol, which causes more side effects and prolongs the abortion over more days or they may need to provide a procedure to complete the abortion.

Could the shift to a one-drug medication abortion with misoprostol come with risks?

Yes. A lot of providers are not comfortable with using misoprostol alone because this is not the current standard of care. For this reason, I think there will likely be a transition process as clinicians get up to speed on protocols on how to provide it, and that will cause a disruption in abortion care.

At the same time, because misoprostol alone is less effective when used without mifepristone, it may be riskier because the chance of a successful abortion is lower. This means that in states with abortion bans, people could end up having to seek additional care to complete the abortion, which could open up everyone involved to legal risk.

Topics