Last week, Jamie Phifer, a Seattle-based family physician, did something she has done regularly for the past decade: She had an appointment with a patient seeking an abortion.

But this appointment was different from many of the others that came before, because it was virtual. The woman was in another state, sitting in her car in her driveway, while her kids were inside on virtual school, Phifer said. The two spoke by video call.

About 36 hours later, abortion pills arrived at the woman’s doorstep.

“She was profusely grateful for rapid care,” Phifer said. “She couldn’t easily arrange child care, as her town didn’t have abortion providers close by.”

The patient was one of the first Phifer saw through Abortion on Demand, a new platform she launched on April 16 — and financed with her savings, she said — that provides abortion pills to people by mail. In conjunction with a mail-order pharmacy, she dispenses the abortion pills to patients located in 20 qualifying states plus D.C. through virtual appointments, an increasingly common practice during the pandemic known as telemedicine.

The launch of Abortion on Demand was made possible by the U.S. Food and Drug Administration’s announcement earlier this month that doctors could distribute mifepristone — a drug taken with a hormone blocker called misoprostol to end an early pregnancy, up to 10 weeks’ gestation — by mail during the covid-19 pandemic. Before the announcement, the agency required health-care providers to distribute mifepristone to patients in person, at clinics, medical offices or hospitals, although patients were not required to actually take the drug in those locations — making it the only drug of the 20,000 the FDA regulates subject to such regulations, according to the American Civil Liberties Union.

FDA acting commissioner Janet Woodcock announced the agency’s decision to make mifepristone available by mail in a letter to the American College of Obstetricians and Gynecologists, one of many medical groups that has sued over restrictions on distribution of the drug under the Trump administration. Woodcock noted that the agency’s review of recent studies shows it’s safe for people to take the pill without receiving it from a doctor in person, and that providing the pill by mail could lessen the risk of spreading the coronavirus.

Antiabortion groups opposed the FDA decision. American Life League, a Catholic organization, called the news “a major loss for the babies.” Jeanne Mancini, president of the antiabortion group March for Life, said the FDA’s change would put women in danger.

“Chemical abortions should have more medical oversight not less,” Mancini said in a statement.

Research shows that mifepristone, used in conjunction with another pill, misoprostol, is overwhelmingly safe and effective when used to end a first-trimester pregnancy. More than 3.7 million women have used mifepristone to facilitate a medication abortion since the drug was first approved by the FDA in 2000, according to research from the University of California at San Francisco. Of those millions of abortions, 24 women have died, but the FDA asserts that those deaths “cannot with certainty be causally attributed to mifepristone.”

The legal battle over mailing the abortion pill

The FDA’s decision marked the latest chapter in an ongoing legal and political battle over the drug, as abortion opponents in Republican-led states have sought to block access to the abortion pill through telemedicine.

Although abortion by medication is legal in every state, 19 states prohibit the use of telemedicine to prescribe abortion pills, including by requiring the clinician providing a medication abortion to be present when the drug is administered. The FDA’s announcement will not override those state laws, according to Julia Kaye, staff attorney at the ACLU’s Reproductive Freedom Project and the lead counsel in two federal lawsuits seeking to eliminate restrictions on mifepristone distribution for abortion.

But now that the FDA has authorized mifepristone to be at least temporarily available by mail in the majority of states, Phifer and many other providers hope the decision will become longer-lasting, beyond the pandemic. They argue making the abortion pill permanently available by mail and via telemedicine would provide more people with easier access to abortions, as the barriers that come with traveling to physical clinics will be eliminated or lessened.

“We as a society have forced these people to remain pregnant,” Phifer said. “As a woman and an abortion provider, it’s infuriating.”

Last July, in a lawsuit brought by the ACLU for which Kaye was lead counsel, a federal judge suspended the requirement that mifepristone be administered in person, opening up the possibility for sending the drug by mail during the pandemic. In the months that followed, a slate of telehealth abortion pill providers emerged, including Choix, HeyJane and Just the Pill. But in January, the Supreme Court sided with the Trump administration, which had appealed the decision, by reinstating the in-person requirement for the distribution of mifepristone. (Choix, HeyJane and Just the Pill are currently providing mifepristone by mail to patients in qualifying states.)

But now that the FDA has changed the rule itself, that decision is irrelevant, and abortion patients can again access mifepristone by mail in the states that lack restrictions on medication abortion by telemedicine, Kaye said. Representatives for the FDA did not respond to The Lily’s inquiries, including about how long its decision is valid and whether it has any plans to make mifepristone permanently available by mail post-pandemic.

An increase in popularity

Medication abortion has become increasingly popular over time: A 2019 report published by the Guttmacher Institute, a research and policy organization focused on sexual and reproductive health and rights, found that as of 2017, an estimated 40 percent of all eligible abortions — up to 10 weeks’ gestation — were medication abortions.

The increasing popularity of the procedure is due, in part, to the ease of access and privacy it provides, according to Elisa Wells, co-founder and co-director of Plan C, a website offering information and resources about abortion pills, including a guide on how to get them.

“You have the confidentiality and control over the process,” Wells said.

The pandemic brought increased demand for abortion pills through telemedicine, when many patients were afraid or unable to leave their homes, according to Tara Shochet, director of the TelAbortion Project, a study evaluating the use of telemedicine in providing medication abortions. Since 2016, the TelAbortion Project has provided 1,700 medical abortions in 17 states plus D.C., Shochet said. Last year, the study’s enrollment doubled from January and February to March and April, Shochet said — an increase she attributes to abortion access challenges exacerbated by the pandemic.

“For any visit [to an abortion clinic], you’re looking for getting time off work, for having child care, for transportation,” Shochet said. “The idea of this from the outset was to address an access gap, and then you throw in a pandemic and all of the things that come with that — kids at home, people at high risk — and that’s really where we were thinking, ‘This is going to fill a lot of that need.’ ”

For lower-income people — who are disproportionately people of color — and people living in rural areas, these challenges become compounded by their circumstances, said Ushma Upadhyay, an associate professor in the department of obstetrics, gynecology and reproductive science at UCSF. Upadhyay was the co-author of a 2018 study that found 27 abortion deserts in the United States, defined as cities from which people must travel more than 100 miles to reach an abortion facility, most of which are in the South and Midwest.

But even people who live closer to clinics may face internalized shame about visiting them — particularly if others perceive them as not belonging there, according to Marybec Griffin, an assistant professor of health behavior, society and policy at Rutgers School of Public Health.

“If your gender identity is something that presents as a person who may not traditionally need [abortion] services, oftentimes there is a stigma and discrimination that comes with that,” Griffin said.

And “for people with disabilities, it sometimes may be a bit more difficult to access a facility” — making abortion pills by telemedicine possibly even more appealing, she added.

What’s next?

Abortion advocates are hopeful that under the Biden administration, the FDA will decide to permanently authorize the distribution of abortion pills by mail and via telemedicine. Skye Perryman, general counsel and chief legal and policy officer for ACOG, the organization that acted as the lead plaintiff in the lawsuit against the FDA last July, said the recent announcement “gives us reason to be hopeful that this administration and this agency will prioritize evidence and equity, and will seek to make sure that abortion care is accessible to people in the U.S.”

In the meantime, the ACLU is challenging FDA restrictions in a federal lawsuit — for which Kaye is also lead counsel — seeking to eliminate the in-person restrictions permanently. Arguments in that case will begin this summer, Kaye said. If the ACLU were to win that case, it could eventually advance to the Supreme Court if the FDA were to appeal the outcome.

Wells and her team at Plan C believe abortion pills secured through telemedicine will only become more popular as time marches on.

As she put it: “We think this is one of the mechanisms by which abortion will be available in the future.”

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