Protesters take to the streets outside the U.S. Supreme Court on Tuesday, March 26, 2024, where justices questioned attorneys about broad changes in access to mifepristone. (Sofia Resnick/States Newsroom)

WASHINGTON—As the enormous yellow banner unfurled in front of the steps of the U.S. Supreme Court Tuesday morning, Laura Clime-Coates turned to her 9-year-old daughter and said, “Those are the names of people who agree with us.”

On the sign, titled “We the People Support Medication Abortion,” were what activists estimated to be half-a-million signatures from people across the U.S. asking the Supreme Court not to restrict mifepristone, a commonly used drug for abortions and miscarriage management. And for Clime-Coates, who said she signed several petitions in support of medication abortion, mifepristone is the reason her oldest child was standing beside her, and the reason she has a little sister at home in Baltimore.

Back in 2009, Clime-Coates said she experienced what she referred to as a missed miscarriage.

“There was no heartbeat, and it was risking my future ability to have children, and I really wanted children,” she told States Newsroom. “The tissue was not developing and threatening my uterus. My choice was to wait around and damage my body or take mifepristone.”

Clime-Coates and her daughter were among hundreds of abortion rights supporters holding signs and chanting, while inside, the justices heard oral arguments in U.S. Food and Drug Administration v. Alliance for Hippocratic Medicine, their first major reproductive rights case since overturning Roe v. Wade almost two years ago.

In the absence of a legal precedent protecting the right to terminate a pregnancy, the implications for abortion access in this case are as high as they have ever been. More than a dozen states have banned or heavily restricted abortion since 2022’s Dobbs v. Jackson Women’s Health Organization decision, but abortion rates have risen rather than fallen. The Guttmacher Institute recently published data estimating more than 1 million abortions in 2023, of which about 63% were via medication, and that only includes abortions in the formal medical system. Many reproductive rights researchers and providers credit the rise in part to the FDA lifting certain restrictions on abortion medication after more than two decades of consistent safety and efficacy data. Beginning in 2016, the FDA increased the gestational window women could terminate pregnancies using medication, adjusted the dosages, removed in-clinic requirements, and made medication abortion available via telemedicine and directly at pharmacies.

Initially filed in 2022 by anti-abortion doctors and medical groups a few months after Roe was overturned, the case has incurred criticism from throughout the medical and scientific community because of its flawed scientific claims that mifepristone is dangerous and should not have been approved by the FDA. At issue now in the FDA’s appeal to the Supreme Court is whether to uphold the 5th U.S. Circuit Court of Appeals’ opinion that the FDA must reapply older restrictions against the agency’s own scientific determination. The coalition of anti-abortion medical groups?have largely relied on anecdotes from longtime anti-abortion activists, as well as a handful of studies produced by some of the main medical groups connected to the lawsuits, two of which were recently retracted by academic publisher Sage for methodological flaws and undisclosed conflicts of interest.

In anticipation of the oral arguments in this case, those in the pharmaceutical industry have expressed anxiety that a ruling against the FDA could stifle future drug development, by allowing anyone with an ideological opposition to a medication to try to force a drug-policy change.

“This case isn’t about mifepristone,” said Elizabeth Jeffords, the CEO of a small biotech company called Iolyx Therapeutics, on a webinar organized by reproductive health researchers last week. “This is about whether or not the FDA is allowed to be the scientific arbiter of what is good and safe for patients. …. It’s critical for our ecosystem that we continue to have investors, and investors will only come to our ecosystem if they have some certainty. If I had to believe that I would have to stand up to multiple litigations from parties without standing over the course of any drug that we’re working on developing, I wouldn’t have enough money to exist, and all of the little biotech companies would be out of existence as well.”

Pharmaceutical sciences professor Chris Adkins – who sparked the investigation into those studies and has co-authored a new academic paper in the journal Contraception breaking down what he says are significant methodological flaws – said it has been difficult to watch this case advance all the way to the Supreme Court.

“I just hope moving forward that we’ve got more public awareness that our federal courts have not always been the best evaluators of scientific evidence,” Adkins told States Newsroom. “I really hope that the public can really put some pressure on the courts to do a better job at evaluating the scientific and the medical literature, because I think this all impacts each one of us, our families, our futures. … This type of case could threaten regulatory approval or the processes they’re involved with, not just for mifepristone, but for others.”

But for both abortion opponents and supporters outside the Supreme Court Tuesday, the issue is personal.

“I was really glad I had that choice,” Clime-Coates said. “It’s health care! And I would hate for any of my children or any woman or anyone who’s capable of reproduction to not have that choice in the future.”

Alethea Shapiro, a protester from Florida, told States Newsroom she needed mifepristone years ago to terminate a pregnancy for medical reasons. “Hands off our mifepristone!” she yelled in a small circle of activists organized by the Women’s March and the Center for Popular Democracy. Some of the activists had prepared for arrests, but they eventually dispersed while law enforcement officers surveilled the crowd.

Robin Ross, an anti-abortion activist from Amarillo, Texas — home of the conservative federal district court where the case was originally filed, told States Newsroom she had secretly attended abortion rights demonstrators’ planning session the night before but said she learned little beyond logistics. The 57-year-old Navy veteran said she recently became an activist after learning that her teenage mother had attempted to abort her in the 1960s, before abortion was legal throughout the country. Ross said that she has had many health problems, including the inability to have children, because of the abortion attempt (she did not give specifics, but she said it was not the medication abortion method authorized by the FDA, at issue in this lawsuit). She is currently working to make Amarillo a so-called sanctuary city for the unborn.

“As soon as I heard about the ability to put my faith into action and me as an abortion survivor, I instantly wanted to start [anti-abortion activism].

Some anti-abortion activists proudly displayed their pregnant bellies in protest of medication abortion.

“I’m here because I’m 34 weeks’ pregnant. I’m advocating for the rights of my child, my baby in the womb,” said Savannah Evans from Tampa, Florida, who does marketing for the national anti-abortion group Live Action. “ I don’t want her to grow up in a world that sees an abortion as an acceptable option for women.”

At 22, Evans said her pregnancy was unplanned and that she was initially “terrified,” but she and her now-husband chose to parent.

Among the speakers in the largely outnumbered anti-abortion crowd, messages focused heavily on alleged high risks of medication abortion and called on the Supreme Court to order the FDA to reapply the since-lifted restrictions that have made it possible for women to have medication abortions via telemedicine and in their homes.

“FDA, do your job!” shouted Marjorie Dannefelser, the president of Susan B. Anthony Pro Life America. “We certainly do not have complete agreement upon the fact that there are two patients in every pregnancy, but we can at least pledge ourselves to one patient: the woman receiving abortion drugs in the mail in her home alone. … She has become her own abortionist in an unsafe home abortion.”

Recent research on telemedicine abortions, co-authored by University of California San Francisco epidemiologist Ushma Upadhyay, finds a low rate of serious adverse risks. And reproductive rights activists working to expand medication access around the nation said in interviews that abortion drugs are here to stay, even if the Supreme Court sides with the anti-abortion activists, which as States Newsroom reported Tuesday, is far from a sure thing.

“We know that people, no matter what happens with this case, are going to continue to access pills outside of the formal health care system,” said Bethany Van Kampen Saravia, senior legal and policy advisor at Ipas, which for decades has worked in countries with restrictive laws to train providers and help expand access to abortion care. Since the overturning of Roe, she said Ipas has refocused their efforts throughout the U.S., where at least half the states have near-total bans or heavy restrictions. As States Newsroom recently reported, new data shows a rise in self-managed abortions since the Dobbs decision.

“People will continue to get medication abortion through online access, through telehealth service, through online pharmacies, through your community network,” Van Kampen Saravia said. “Self-managed abortion is a WHO-recommended method of care. What Ipas knows from decades of working outside of the U.S. is that abortion with medication is safe and effective. And that’s not going to stop no matter what happens.”

Abortion providers who work in and outside of the formal medical system told States Newsroom they should be able to prescribe the current medication abortion regimen off label, if the FDA is ordered to change its protocol.

“We’re continuing to work because the pills are still on the market, they’re still registered, so they will be available and the doctors have the freedom to prescribe them off label,” said Dutch physician Dr. Rebecca Gomperts, founder of the online clinic Aid Access, which she said has been working with states with shield laws to ship abortion drugs to women in states with abortion bans. She was in front of the court handing out, for free, a small amount of boxes of the abortion-medication regimen. She said Aid Access will continue helping women self-manage their abortions.

“No matter what the Supreme Court is going to do, we’ll be there,” Gomperts said.