March 30 2024 Women’s Rights of Bodily Autonomy and Reproduction: the Case of Mifepristone
A mail order abortion drug for home use which is safer than many non prescription drugs and decades of use after hundreds of FDA clinical trials, has been challenged in our Supreme Court by a radical and fractional shadow …
A mail order abortion drug for home use which is safer than many non prescription drugs and decades of use after hundreds of FDA clinical trials, has been challenged in our Supreme Court by a radical and fractional shadow organization of anti-abortion radicals who wish to subvert democracy, the equality and rights of bodily autonomy and reproduction of women, the principle that medical decisions are between a doctor and patient, and the institution of the FDA in approving pharmaceuticals as safe for human use; a broad attack across American values and our social and institutional spheres.
This assault on the public good and the citizenship and liberty of all women through multiple legislative and judicial fronts of action foregrounds and hinges on abortion and includes the vote and citizenship of women, but does not end there. Our rights as citizen and as human beings are parallel and interdependent and designed to reinforce each other; if rights of bodily autonomy and reproduction are lost, women become dehumanized chattel slaves, and this is the end goal of the Republican Party as an organization of patriarchal sexual terror and theocratic tyranny.
Abortion is the key issue which will secure the next election for a Democratic Party President, because it is one we can win. The overwhelming majority of Republicans, both women and men, also favor a woman's right to choose; if well played this will become a lever of change within the Republican Party which may one day liberate it from capture by Christian Identity fundamentalists who seized it in 1980 and from the Fourth Reich who in the Stolen Election of 2016 used it to capture our nation under the figurehead of a rapist President.
What would such a world be like to live in? Margaret Atwood has given us a vision of our future under a patriarchal theocracy in The Handmaid's Tale.
The Handmaid's Tale gives a voice to Bilhah, the Biblical Handmaid, revisions Little Red Riding Hood as an extension of Angela Carter's The Company of Wolves, and tells the story of the Christian disempowerment of the Goddess and the dawn of the age of patriarchal theocracy as presented in the great film The Red Shoes.
Margaret Atwood's parodies of Grimm operate on three levels; thematic, images and motifs, and narrative structure. In The Handmaid's Tale, we have themes of family and especially female-female conflict, gender and sexual power asymmetries, and the initiation and heroic journey. Motifs and images include dismemberment, cannibalism, fertility, labyrinths and paths, and all manner of disturbing sexual violence. Plot devices include a variety of character foils, doppelgangers, disguises and trickery of stolen and falsified identity.
Among Margaret Atwood's Great Books, The Handmaid's Tale is a universally known reference both because it has been taught for over a generation in every high school in America as a standard text and because of the extraordinary television series, arguably the most important series ever filmed. We teach it for the same reasons the show is popular; a visceral and gripping drama with unforgettable characters, a mesmerizing plot, and an immediate and accessible story which interrogates a universal system of oppression and also empowers resistance and illuminates our autonomy and self-ownership.
It depicts the brooding evil and vicious misogyny of Christianity and Fascism as two sides of the dynamic malaise of authority as patriarchy and tyranny, sexual and racial terror institutionalized as religion and state, as drawn directly from Arthur Miller's The Crucible and Hawthorne's Scarlet Letter, but also from contemporary culture as it contains satires of identifiable public figures, organizations, and events. Serena is based on Phyllis Schlafly, and Gideon is the nation of Pat Robertson and the fundamentalists who seized control of the Republican Party in 1980 around the time of the novel's writing; Margaret Atwood's motive in part was to sound an alarm at the dawn of the Fourth Reich and its threat to global democracy.
It remains to be seen whether the forces of tyranny or of liberty will prevail in the end. Each of our lives is a contest between these forces, our private struggles reflected in the society and human civilization we share.
And this is the great lesson and insight of Margaret Atwood; each of us is both a Handmaid and a Serena, trapped within the skin of the other. She locates the primary conflict within ourselves, and transposes the Jungian conflict with the Shadow in terms of sex, gender, and power, while interrogating those same universal systems of oppression in our society and political institutions.
Whence comes this madness?
As written by Jordan Smith in The Intercept, in an article entitled The Shadow Medical Community Behind the Attempt to Ban Medication Abortion; THE ALLIANCE FOR HIPPOCRATIC MEDICINE, a new anti-abortion umbrella group that is spearheading a sweeping federal challenge to medication abortion, incorporated in Texas just months before filing suit. The incorporation documents, obtained from the Texas secretary of state, provide further evidence that the plaintiffs cherry-picked a court they believed would be amenable to their arguments, an act of forum shopping that was orchestrated to land the case before Judge Matthew Kacsmaryk, a Trump-appointed darling of the far right.
The Alliance incorporated in Amarillo in August 2022, bringing together five out-of-state anti-abortion groups: the Catholic Medical Association, the Coptic Medical Association of North America, the American College of Pediatricians, the Christian Medical & Dental Associations, and the American Association of Pro-Life Obstetricians and Gynecologists. Three months later, the lawsuit was filed in the same Texas Panhandle city where Kacsmaryk hears all federal civil cases.
The lawsuit alleges that in 2000, the Food and Drug Administration, or FDA, wrongly approved mifepristone, the first of two drugs that make up the standard medication abortion protocol. The groups also argue that sending abortion medications through the mail violates federal criminal law. To advance their argument, the plaintiffs have assembled a raft of dubious evidence to allege that the FDA is anti-science and mifepristone is a wildly dangerous drug, despite decades of scientific research and hundreds of medical studies that demonstrate otherwise. They have dished it all up for a federal judge who, in just a short time on the bench, has developed a reputation for factitious legal opinions. A ruling in their favor could see medication abortion all but banned across the U.S., sparking a new round of chaos after the fall of Roe v. Wade and laying the groundwork for the dispute to land before the U.S. Supreme Court.
Suspect Assertions
Medication abortion is a two-drug protocol designed for use in early pregnancy termination. The first drug, mifepristone, blocks progesterone (a hormone needed to maintain pregnancy) and softens the uterine lining; the second drug, misoprostol, is taken 24 to 48 hours later and causes the uterus to contract, expelling the pregnancy.
The regimen was developed in France in the late 1980s, but it wasn't until 2000 that the FDA finally approved it for use in the United States. Medication abortion accounted for just 5 percent of abortions in 2001 but has steadily grown in popularity; today, medication abortion accounts for more than half of all pregnancy terminations in the country. The protocol is also commonly used for miscarriage management.
The FDA has enforced a slew of restrictions tied to mifepristone that advocates and providers have long argued are medically unnecessary — including a rule that it must be dispensed in person, even though misoprostol is not taken until later at a place of the patient's choosing. During the pandemic, the in-person dispensing rule was blocked, and in December 2021, the FDA announced that it was permanently lifting the requirement. The agency has since taken additional steps to expand access to medication abortion by allowing mail-order and brick-and-mortar pharmacies to dispense it to patients with prescriptions in states where abortion is legal.
It was against this backdrop that the Alliance for Hippocratic Medicine, its partner organizations, and several individual doctors — represented by lawyers with the Christian-right Alliance Defending Freedom — filed suit in Texas, arguing that the FDA never should have approved mifepristone in the first place, let alone expand its use or loosen dispensing requirements.
The filing is a jumbled mess of suspect assertions, cloaked in inflammatory and medically inaccurate language. The filing refers to medication abortion as "chemical" abortion and claims that mifepristone "starves the baby to death." It alleges that medication abortion is far riskier than procedural abortion or carrying a pregnancy to term, which the plaintiffs argue "rarely" leads to threatening complications. They call mifepristone an "endocrine disrupter" that could threaten the normal development of adolescents who take it. And they assert that individuals suffering complications from medication abortion could "overwhelm" the health care system, leading to a flood of blood transfusions that "exacerbates the current critical national blood shortage."
These allegations are baseless. An endocrine disrupter is a chemical that mimics or interferes with the body's hormones, such as PFAS, a class of toxic "forever" chemicals found in dozens of common products that has been linked to cancer and other illnesses. The notion that mifepristone — taken in a single dose — falls into this camp because it "briefly blocks progesterone receptors in the uterus is completely unfounded," according to an amicus brief filed in the case by the American College of Obstetricians and Gynecologists, the American Medical Association, the American Academy of Family Physicians, and eight other leading U.S. medical groups. "There is no reason to think, nor is there evidence to show, that preventing the absorption of progesterone for a brief window would have any effects on adolescent development," the brief states.
The assertion that medication abortion is a risky and understudied endeavor recklessly approved by the FDA is equally spurious. To date, mifepristone has been used in more than 630 published clinical trials, including more than 420 randomized, controlled studies, which the amicus brief notes are the "gold standard of research design." At less than 1 percent, the risk of serious complications is exceedingly low. The likelihood of any complication at all is about 5 percent; the most common is an incomplete expulsion, which may require a procedural abortion to complete. Meanwhile, the risk of death associated with carrying a pregnancy to term is 14 times higher than the risk associated with abortion.
"Mifepristone's safety profile is on par with common painkillers like ibuprofen and acetaminophen, which more than 30 million Americans take in any given day," according to the amicus brief. Procedures like wisdom teeth removal, colonoscopy, and plastic surgery have higher complication and death rates, as does the use of Viagra. "Put simply," the brief states, "medication abortion is among the safest medical interventions in any category — related to pregnancy or not."
Behind the Scenes
The fight over abortion has long featured a shadow medical community that exists to promote counterfactual narratives about risks associated with the procedure. To Mary Ziegler, a law professor and legal historian at the University of California, Davis, the fact that the Alliance for Hippocratic Medicine was established to go after medication abortion isn't surprising.
"There's a tradition of groups like this forming," Ziegler said. Back in the 1990s, for example, a group called the Physicians Ad Hoc Committee for Truth sprang up for the purposes of advocating for a ban on dilation and extraction abortion, which anti-abortion forces dubbed "partial-birth abortion." Once Congress passed the ban, the committee disappeared.
While the Alliance for Hippocratic Medicine itself is a new entity, presumably incorporated to bolster the pending lawsuit, the groups organized under it have been around for a long time. The American Association of Pro-Life Obstetricians and Gynecologists, known as AAPLOG, formed in the wake of the 1973 Roe decision, initially as an affinity group of anti-abortion physicians who belonged to the American College of Obstetricians and Gynecologists, or ACOG, the country's leading professional membership organization for OB-GYNs.
Over time, AAPLOG began to push back against the medical and scientific establishment, developing a narrative that abortion was not only immoral, but also dangerous. The group focused more on disputing the "factual premises of things ACOG was saying, rather than just disputing the morality or ethics of those decisions," Ziegler said. "Medical arguments against abortion bans were effective enough that they needed to be met with medical arguments for abortion bans," she explained. "There's an appetite for these organizations to have their own narratives."
AAPLOG has since split from ACOG and now has roughly 7,000 members compared to ACOG's more than 60,000 (anyone can join the former, while the latter's membership is limited to medical professionals). Despite its size, AAPLOG has successfully pressed its counternarrative in legislative and legal crusades to restrict or ban abortion, even when the scientific underpinning for its position is shaky.
Take the work of George Delgado, one of the named plaintiffs in the Alliance for Hippocratic Medicine lawsuit. A doctor in Southern California, Delgado developed so-called abortion pill reversal: the notion that a person who changes their mind about going through with a medication abortion after taking mifepristone (but before taking misoprostol) can interrupt the process by taking a large dose of prescription progesterone to reestablish the pregnancy. There is no evidence that the protocol is safe or effective; the only controlled study designed to interrogate it was halted based on "safety concerns" after three of 12 participants hemorrhaged and were taken to the hospital. Still, AAPLOG has deemed medication abortion reversal a "medically sound choice" and supported state efforts to mandate counseling on reversal for anyone seeking abortion.
"When you have arguments about science that are not based that much in evidence, not only is it confusing and obviously can lead to really bad outcomes, but it's also disenfranchising."
While the alternate narratives pushed by groups like AAPLOG may be politically powerful, they are also dangerous, offering the imprimatur of science without sound foundational support. "When you have arguments about science that are not based that much in evidence, not only is it confusing and obviously can lead to really bad outcomes, but it's also disenfranchising," Ziegler said. "Because normal people don't know anything about these topics, right? They don't know about the relative rate of complications of mifepristone. And so if what's really going on here is a struggle over constitutional values and ethics and so on, we should be telling the truth about that."
The shadow medical community's efforts to legitimize various abortion restrictions have been effective — like a requirement that abortion doctors maintain hospital admitting privileges, which groups including AAPLOG claimed was a best practice designed to ensure patient safety. Broadly speaking, such efforts worked in front of state lawmakers but typically failed at the Supreme Court.
Now, with Roe in the rearview mirror and no immediately obvious need to keep pressing such pseudoscience, Ziegler suspects that groups like AAPLOG are still leaning into these arguments because their real aims — like establishing fetal personhood rights — "are still not popular," she said. Anti-abortion ballot measures have repeatedly failed with voters, and a significant majority of Americans say abortion should be legal in all or most cases. "And so they're having to take their claims to courts and to judges like Judge Kacsmaryk … and they're having to rely on weird interpretations of FDA regulations." This is "not a window into what they think is the most important," she said, but "what they think will work."
A Slippery Slope
Before being tapped to serve as the federal district court judge in Amarillo, Kacsmaryk worked at the religious-right First Liberty Institute, which, among other things, opposes the separation of church and state. Kacsmaryk has been vocal about his disdain for gay marriage, reproductive rights, and transgender people. In 2016, he signed onto a letter that called being transgender an "irrational … delusion" (the Catholic Medical Association, which is a party in the mifepristone lawsuit, was also a signatory). And he's written that the sexual revolution was destructive, seeking "public affirmation of the lie that the human person is an autonomous blob of Silly Putty unconstrained by nature or biology, and that marriage, sexuality, gender identity, and even the unborn child must yield to the erotic desires of liberated adults."
While on the bench, Kacsmaryk has made a string of controversial rulings: He declared Biden administration protections for transgender workers unlawful; twice ordered the administration to enforce the Trump-era "Remain in Mexico" policy; and attacked Title X, the only federal program designed to provide birth control to low-income and uninsured people.
In the Title X case, Deanda v. Becerra, Kacsmaryk sided with Texas father Alexander Deanda, who was challenging the program based on its guarantee of patient confidentiality. Deanda claimed that the program violated his rights as a parent raising his daughters according to "Christian teaching on matters of sexuality." With Title X in place, he argued, he had no assurance that his daughters would be "unable to access … contraception" and other services that "facilitate sexual promiscuity."
Among the criticisms leveled at Kacsmaryk in the wake of his ruling in favor of Deanda was that he lacked power to consider the case in the first place. To bring a federal lawsuit, a plaintiff must show they've been injured by the law they're challenging, but Deanda — who never alleged that his children attempted to avail themselves of Title X services — hadn't been harmed. Deanda had no standing to bring the suit, in other words, and Kacsmaryk had no cause to hear it. Nonetheless, Kacsmaryk ruled that the Title X program as administered violated the "constitutional right of parents to direct the upbringing of their children."
In response to the pending mifepristone lawsuit, the federal government has argued that the FDA's approval of the drug in 2000 was based on years of solid research, that the statute of limitations to challenge that approval has since run out, and that, like Deanda, the plaintiffs have no standing.
The FDA argues that neither the medical associations nor the individual doctors bringing the suit have suffered any injury related to the drug's approval. And indeed, the plaintiffs' claims of injury are tenuous. While the doctors who are party to the lawsuit don't provide medication abortion, they argue that they may one day find themselves in a situation where a person allegedly harmed by mifepristone comes to them for treatment, thus drawing their attention away from existing patients. And they say that these impaired patients may present with an incomplete abortion, which would conscript the doctors into providing services that violate their conscience. Meanwhile, the organizations argue that the approval of mifepristone has forced them to divert time and energy away from other priorities, like advocating for fetal personhood, forcing them to focus instead on "educating" their members about the dangers of medication abortion.
To the FDA, this theory of legal injury is nonsense — and a slippery slope: Allowing the case to go forward would greenlight other baseless legal complaints, it argues in response to the Alliance lawsuit. "If FDA approved a new heart medicine, emergency physicians would have standing to challenge the approval on the theory that some patients would experience adverse events under the new treatment; in contrast, cardiologists would have standing to challenge the approval on the theory that some patients would no longer require their services."
A Zombie Law
In a response filed in early February, the Alliance Defending Freedom lawyers brushed off the government's arguments about standing — the doctors and organizations bringing the suit had "standing six ways from Sunday," they asserted. They doubled down on their fearmongering, arguing that medication abortion had never been studied under "real-world conditions," and that the doctors bringing the suit actually "treat and care for countless victims of this dangerous drug regimen."
The plaintiffs also leaned into allegations that allowing medication abortion to be mailed to patients violates the 19th-century law known as the Comstock Act, which outlawed sending anything considered "obscene, lewd, lascivious, indecent, filthy or vile" through the mail, including contraceptives and "every article or thing" that could be used for abortion. Over the years, judicial and congressional actions have largely neutered the act, and in late December, the Department of Justice penned an opinion noting that the law does not apply where abortion is legal or when the sender doesn't intend that the recipient would use the drugs illegally. But the Comstock Act is still on the books, a zombie law that the Alliance plaintiffs are trying to raise from the dead.
The End of Roe
If Kacsmaryk agrees that the Comstock Act applies to medication abortion, the impact could be far-reaching. The act forbids the mailing of any device that may be used for abortion, which would include countless medications and routine gynecological instruments. It could also impact the availability of misoprostol, which absent mifepristone, can be used alone to accomplish an abortion. It is not as effective as the two-drug regimen but has for decades been used safely for that purpose; the Alliance lawsuit does not attack FDA approval of misoprostol.
A hearing in the case has yet to be scheduled. Meanwhile, a coalition of 12 states, led by Washington and Oregon, filed their own lawsuit last week asking another federal judge to rule that mifepristone is safe and effective and that its FDA approval is "lawful and valid." The states are asking the judge to eliminate all remaining FDA-imposed restrictions on mifepristone, which they argue impermissibly impede access to the drug.
On February 24, Vice President Kamala Harris met with reproductive rights advocates and medical experts, including from ACOG and the American Academy of Family Physicians. The Alliance lawsuit is not just an attack on "women's fundamental freedoms," she warned. "It is an attack on the very foundation of our public health system."
"Those who would attack … the ability of the FDA to make a decision" about approving a drug like mifepristone "ought to look in their own medicine cabinets to figure out whether they're prepared to say those medications … should no longer be available to them," she said. "Because that is what we are talking about."
Where are we in this fight now?
As written by Moira Donegan in The Guardian, in an article entitled Even the US supreme court was baffled by conservatives' attack on abortion pills; "It is a testament to how weak the plaintiffs' case is that the justices seemed so skeptical. Erin Hawley, a lawyer for the far-right antifeminist litigation shop Alliance Defending Freedom and the spouse of the conservative US senator Josh Hawley, usually gets a much warmer reception at One First Street. But in Tuesday's oral arguments in Alliance for Hippocratic Medicine v FDA – a lawsuit which seeks to challenge FDA approval of the abortion drug mifepristone, and specifically to reverse regulatory changes that made the drug more easily accessible – she was on the defensive.
The three Democratic appointees, along with the Republican justices Gorsuch, Kavanaugh and Roberts, all signaled at least some skepticism of her clients' claims to legal standing. Amy Coney Barrett, the Trump appointee known for her maximalist religious commitments, struggled to help Hawley establish a convincing merits case to restrict access to the drug. And the far-right extremists Samuel Alito and Clarence Thomas spent their question time signalling their support for the Comstock Act, a long-obscure and once-forgotten 1871 statute that some anti-choice lawyers say could be used to ban abortion nationwide by executive order.
Alliance for Hippocratic Medicine has always been a strange case, one whose path to the court was marked by controversy, strained argument and dramatically lowered legal standards. For one thing, the plaintiffs, a group of anti-abortion doctors who make outlandish and empirically disproven claims about the supposed dangers of mifepristone, hand-picked their own trial judge. They filed their lawsuit in the northern district of Texas, a federal court in Amarillo that has only one judge: Matthew Kacsmaryk, a young Trump appointee with a history of militant anti-choice activism who has become famous for his extreme deference to anti-abortion litigants.
Kacsmaryk ignored the fact that the physician plaintiffs could not show any injury that would entitle them to sue, and promptly issued a national injunction revoking FDA approval of the drug – an unprecedented judicial intervention that threatened to end access to a medication that is used in more than half of US abortions.
Above him, the far-right fifth circuit, in an opinion authored by the aspiring supreme court nominee James Ho, upheld the FDA's initial approval of the drug but ruled that interventions in 2016 and 2021 that had made it more accessible were illegal, a move that would have made the pills dramatically more difficult to get in a post-Dobbs world. In his opinion, Ho not only bypassed the case's initial standing problems, but made bizarre arguments justifying the right of virtually anyone to sue over abortion medication – including for what he called "aesthetic injuries" – that is, the harm allegedly done by abortion medication to people who are deprived of the opportunity to look at more babies.
At the supreme court, it was the FDA's post-2016 moves to lower barriers of access to mifepristone that were supposedly at issue. And in theory, this should have been catnip to the revanchist supreme court, which has in recent years enthusiastically taken up legal challenges meant to erode abortion access, curtail civil rights, and weaken federal agencies like the FDA. But with the court's approval at an all-time low in the wake of Dobbs, and with a looming November election to be determined in a large part by public outrage over women's rights, even the court's most enthusiastic enemies of abortion access and federal regulation found themselves with limited appetite to allow plaintiffs to limit access to a safe and popular drug nationwide.
And so it was that on Tuesday, the supreme court rediscovered an area of the law that it has recently been content to ignore: standing doctrine. The minor, inconvenient fact that the plaintiffs have experienced no injury and have no legal right to sue had been hand-waved away in the district court and at the fifth circuit, but it became an issue of prolonged attention in the oral arguments at the supreme court.
Elena Kagan noted that the plaintiff's theory of standing was "highly probabilistic", meaning that it relied on a series of hypotheticals and contingencies about potential harms that might happen, somehow, at some indeterminate point in the future, to someone, somewhere.
Ketanji Brown Jackson issued some of her most pointed questions since joining the court – a high bar – over the asymmetry between the plaintiff's stated injury of a hypothetical future conscience harm and their proposed remedy for that injury – a nationwide restriction on the way all American women can use the drug. Jackson was joined in this line of thought by the Trump appointee Neil Gorsuch, her sometimes odd-couple ally, who asked the anti-abortion camp why they had filed such a broad petition, instead of a narrow one, in a tone I can only describe as scolding.
Roberts signaled a preoccupation with the standing question; even Kavanaugh, a justice with little skill in making a point, asked a question that seemed aimed at getting a fact of established law on the record: don't these physicians already have a legal right to decline to perform abortions? Hawley answered in the affirmative.
The court seems poised to throw out the case on standing grounds; if the opinion is written by a conservative, it will likely operate as something of an instruction manual, describing the kind of case that the conservative legal movement could bring that would successfully overturn the FDA's approval of mifepristone. A future case – just not this one.
But oral arguments on Tuesday did make news: they signaled the first time that the anti-choice movement's preferred strategy for banning abortion nationwide has cheerleaders on the supreme court. The case that the court heard on Tuesday was specifically not supposed to concern the federal Comstock Act, a long-unenforced law left over from the Victorian era that imposed a ban on sending contraception or abortion implements through the mail or trading them via interstate commerce. But both Samuel Alito and Clarence Thomas brought up the act, which plaintiffs mentioned in their briefs and which was the focus of several amici curiae who submitted in the case.
Since Dobbs, anti-abortion litigants have been advancing a novel, never-before-enforced idea that the Comstock Act could be interpreted broadly to functionally ban all abortions nationwide – as well as several kinds of birth control and possibly implements that are also used in other kinds of routine gynecological care, like speculums and curettes. Alito signaled with his questions that he felt the act applied to the FDA, who had failed to heed its prohibitions when they approved the drug; Thomas suggested that mifepristone's manufacturer had violated it when selling and advertising abortion medication.
These interpretations will likely not be controlling opinion in this lawsuit. But they signal how this court may rule under a future Republican administration. After all, if Republicans want to enforce the Comstock Act as a nationwide total abortion ban, they don't need to win control of Congress. All they need is the White House."
Why is this important, and what is this like in the lives of women?
As written by Clea Skopeliti in The Guardian, in an article entitled Women who used abortion pills on US supreme court mifepristone case: 'It's maddening'; "Mercy's periods had always been very regular, so when she missed one in 2016, she immediately took a pregnancy test. It was positive, and she managed to get an appointment at an abortion clinic the next day.
Despite being able to act quickly, she was in her seventh week of pregnancy by the time she could take abortion pills in Ohio – a state that was, at the time, debating banning abortion from the moment embryonic cardiac activity is detected (usually around six weeks). Ohio has since enshrined abortion rights in its state constitution following a referendum.
After the supreme court heard oral arguments this week in its first abortion case since it overturned Roe v Wade almost two years ago, Mercy reflected on her experience of accessing a medical abortion. There have been fears that the case – the US Food and Drug Administration v Alliance for Hippocratic Medicine – could curtail access to medication abortions, though legal experts say it does not appear to be going well for anti-abortion doctors.
When she arrived at the clinic, Mercy, 22 at the time, faced harassment. "There were protesters outside the building. They had signs and a billboard with a chopped-up baby on it. They screamed at me as I entered the building. It felt very threatening and judgmental – I would bundle myself up in hoodies to obscure my identity."
During a follow-up appointment, she arrived just before the clinic had opened, and hid behind nearby bushes to dodge the protesters. "I was terrified," she said. "I felt like a sitting duck."
Despite facing intimidation from protesters, Mercy, now 29, knew she was not ready to be a parent.
"I wanted it, but it wasn't planned," she said. "I wasn't able to have a kid at the time – I was a student and had trouble affording things. There's no way I could have supported a baby."
Amid debates about "heartbeat" bills, Mercy had been aware there were unavoidable delays. At her first appointment, the providers at the abortion clinic were unable to find the embryo with ultrasound and the appointment was rescheduled for a week later. Mercy was then required to wait 24 hours between seeing the ultrasound and obtaining the abortion, but due to her class schedule and clinic opening times, she had to wait another week.
The staff at the clinic were compassionate and non-judgmental, she remembers, saying: "They were fantastic to me. It was one of the most empowering experiences I've ever had. They reassured me it wasn't my fault, I'd taken precautions and things happened."
Her experience taking abortion pills in her seventh week went smoothly. She took the mifepristone in the clinic, and misoprostol later, along with a single dose of an antibiotic, which the doctor told her might make her drowsy. She said: "I just curled up on my bed and went straight to sleep. I don't know how bad the cramping might have been, but by the time I woke up the next morning it was like I was having a heavy period."
She described her experience as being "really straightforward and non-traumatic".
"I was glad to be in a place that I considered safe, without others' judgment and to be able to process it," she said.
Caitlin, 35, underwent a medical abortion at a hospital in California the day after the news leaked that the supreme court would be overturning Roe v Wade in 2022.
"It was a very somber experience, and the doctor prescribing me the medication was clearly incredibly upset," she remembers.
"My nervousness about the abortion was overshadowed by the leak. In some ways it helped with nervousness – like we were all in this experience together – but it was emotionally painful. I realised that in California, it was going to affect me much less than people in other parts of the country – but depending on who's in power in the US, it could turn into a country-wide thing. I wondered: is this the last time I have this operation? I may never want or need it again, but I want to have the option," she said.
Following an ultrasound, which she declined to see, Caitlin took the mifepristone pill in the hospital, and the misoprostol at home. She was nine weeks pregnant. "It was pretty painful," she said. "It's a lot for your body to go through. I thought, no one's doing this because they want to." But she was glad to be at home with support from her partner and roommate.
She said she had been "manically refreshing" the news for updates on the supreme court mifepristone case.
"I'm really nervous about the outcome. I really appreciate the ingenuity of the providers who send medication to the states where abortion is illegal. We've been forced to get creative. I'm not surprised conservatives are trying to reverse the work's that been done," she said. "I see the anti-abortion movement here to be another way to subjugate people in poverty."
Kelly, 46, has had three medication abortions over the years. Her first was in early 2001, shortly after mifepristone had been authorized for use by the FDA in 2000. After unsuccessfully trying to access the morning-after pill in Salem, Oregon, she went to a Planned Parenthood clinic in Portland, where staff confirmed she was pregnant. "It was an accidental pregnancy at 23, I didn't have a permanent job – and I knew from a young age I didn't want children," she said.
Her experience in 2001 – and 2016 and 2017 – of accessing mifepristone at Planned Parenthood in Portland was straightforward, with "very clear instructions" from the clinic. She was prescribed a painkiller to help with the heavy cramping that accompanies the second pill, misoprostol.
Kelly felt that being able to take abortion pills at home made the process easier. "Medical settings give me a lot of anxiety – to do it at home felt more comfortable. My partner made me food, I got to sit on the couch and be in my own bathroom," she said.
"In my later two abortions, I was very settled in my career, but again didn't want kids. I've never had any regrets, never any mental health issues as a result. I've been set on not having children."
Reflecting on the supreme court case, Kelly said: "As a lifelong feminist, I am shocked that were in this level in the US. We're just at a point where access to abortion has been turned on its head in the US. Mifepristone is completely safe. Thankfully, it looks like they're not going to rule in favour [of restricting access] – but the fact it could be [restricted] is maddening."
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Women who used abortion pills on US supreme court mifepristone case: 'It's maddening': Three women share their stories of getting medication abortions, and their thoughts on that access being curtailed
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