As medication abortion becomes more popular and a global pandemic makes telemedicine not just appealing, but necessary to minimize the risk of spreading COVID-19, the anti-choice movement has honed in on a new target: the U.S. Food and Drug Administration (FDA).

Over the last several months, anti-abortion activists and lawmakers have escalated a campaign aimed at the federal agency, asking it to crack down on websites selling abortion pills online and ignore calls to lift the restrictions on the abortion drug mifepristone.

In May, dozens of anti-abortion groups signed a letter to the FDA singling out Aid Access, a telemedicine site run by a doctor based in the Netherlands, which received a warning letter from the agency last year for prescribing mifepristone to patients in the United States. They joined more than 100 anti-choice lawmakers who sent a similar letter to the FDA last year. And large anti-abortion organizations like Students for Life and Live Action are urging activists to focus more heavily on restricting medication abortion and using the issue to raise hundreds of thousands of dollars for the cause. 

Reproductive health advocates say the anti-abortion camp is beginning to view medication abortion as the new frontier of abortion access—and therefore as their next major battle to fight.

“I think they’ve been aware of it but maybe didn’t understand the degree to which it’s a transformative technology especially when combined with the internet and with our global commerce system,” said Elisa Wells, the cofounder of Plan C, a website that provides people with information about self-managed abortion with pills. “They’re clearly concerned because they see the promise of the [abortion pill] to make abortion accessible to those who need it.”

Focusing more heavily on the FDA’s regulation of medication abortion means anti-abortion activists may have to subtly change their strategy. The movement has long relied on abortion later in pregnancy to associate graphic and misleading imagery with abortion in general, and put clinics in the crosshairs of anti-choice legislation, protest, and violence.

Medication abortion “has the potential to move abortion away from a clinic-based service—which is where a lot of activity in the anti-abortion movement is focused—and move that to patients’ homes where it would be a much more private experience,” said Dr. Daniel Grossman, the director of Advancing New Standards in Reproductive Health (ANSIRH), a research group at the University of California, San Francisco. “I’m sure that seems like a big threat to the anti-abortion movement.”

Anti-choice groups are likely to make more of an issue out of the FDA’s role in regulating abortion drugs after a federal judge’s ruling last week, which temporarily suspended the agency’s longtime mandate that providers dispense mifepristone from a hospital or clinic for the duration of the pandemic. 

In the immediate aftermath, anti-choice groups condemned the decision, leaning on misleading claims about the drug’s safety. “The FDA regulation known as the Risk Evaluation Mitigation Strategy (REMS) is in place to ensure the drug is administered by an approved prescriber equipped to accurately assess pregnancy and the risks associated with ingesting the dangerous abortion drug regimen,” Lila Rose, the founder and president of Live Action, wrote in a statement. 

For decades, the restrictions on how the medication can be dispensed have meant that patients could only obtain the pills in person, creating a significant—and medically unnecessary—barrier to medication abortion, which research has shown is overwhelmingly safe and effective.

As of 2017, nearly 40 percent of U.S. abortions were done with pills, according to a Guttmacher Institute report. The method of abortion—a two-step regimen involving mifepristone and misoprostol—is now much more common than it was 20 years ago, when it first became available. But in parts of Europe where the drug is not as heavily restricted, the rate of medication abortion can be as high as 90 percent. 

The FDA placed these restrictions on mifepristone as soon as it approved the drug in 2000. The approval process was contentious, and reproductive health advocates argue that the agency favored anti-choice activists when it decided to implement several restrictions on the drug despite its safety record abroad. 

Abortion rights supporters had hoped that medication abortion would dramatically expand abortion access, imagining that patients would be able to get the pills from primary care physicians or as an over-the-counter medication at pharmacies. Instead, medication abortion became just as difficult to access as other in-clinic abortion procedures. 

“If we had made the pills available 20 years ago, medication abortion would have always been included in anti-abortionists’ strategies and public messaging,” said Cynthia Pearson, the executive director of the National Women’s Health Network. “But they won in the sense that they managed to keep access so limited.”

Pearson says abortion rights opponents are taking advantage of what they view as a politicized FDA that will eventually take their side in the fight over medication abortion access. The FDA resides within the U.S. Department of Health and Human Services, overseen by Secretary Alex Azar, who has pushed through President Donald Trump’s anti-abortion agenda and referred to HHS as the “Department of Life.”

“I think some form of some interference—or ‘wink-wink’ implied interference—is preventing the FDA from making a science-based decision,” Pearson said. “But the restrictions have been political from the start. They were political then, and they’re political now.”

As anti-choice activists adjust their strategy to focus on the FDA and medication abortion, their opponents believe they are gaining ground in the fight to expand access. Even before the federal judge’s ruling rolling back the in-person requirement on mifepristone, Plan C had been in talks with dozens of doctors across the country about mailing the medication anyway, arguing that the FDA rule is vague about whether a patient has to obtain the pills in person. Some have agreed to overlook the longtime interpretation of the rule and mail their patients abortion pills. 

More people also appear to be using websites like Aid Access and abortionpillrx.com to buy abortion pills online—particularly during quarantine—and some are discovering that they prefer to self-administer the medication. 

In the meantime, researchers and reproductive health advocates are hoping they can use this window of time to build an even more persuasive case for getting rid of the mifepristone restrictions permanently.

“In this current administration, everything is politicized,” Grossman said. “But I’m still optimistic that, in the long run, the evidence will be convincing.”