Lila Bonow, Alana Edmondson and Aiyana Knauer prepare to take abortion pill while demonstrating in front of the U.S. Supreme Court on Dec. 1, 2021. (Photo by Chip Somodevilla/Getty Images)

JACKSON, Miss. — The Pink House — otherwise known as Jackson Women’s Health Organization — was the center of the U.S. Supreme Court case that overturned the federal right to abortion in June. Today, the clinic, the only abortion clinic to serve Mississippi and the greater area for years, is shuttered. On a hot day in February, there are no protests outside the clinic’s gates, the air is still and quiet, the iconic walls on the outside have been painted white, and the medical equipment has been removed. A new owner has moved in and has begun converting it into a consignment shop for luxury goods.?

“I worry about those women a lot, that they no longer have means to health care in the state of Mississippi,” said Diane Derzis, former owner of the Pink House.?

The Pink House is just one of dozens of organizations across the South that have closed or stopped offering abortion services in the face of trigger abortion bans that went into effect right after Dobbs v. Jackson Women’s Health Organization overturned Roe v. Wade.?

Derzis said selling the building that housed the clinic was a “business decision.” She said the Jackson clinic’s operations, medical equipment, and furniture have moved to Las Cruces, New Mexico, in the face of Mississippi’s 15 week abortion ban. She also has clinics in places like Columbus, Georgia, and Richmond, Virginia. Now, many people in the South are traveling out of state to seek an abortion — either in-clinic or via medication abortion, she said.?

Derzis says she’s getting ready to open a clinic in Chicago, Illinois.?

But all those clinics and others still operating could soon face new restrictions as a federal judge in Texas decides on a lawsuit filed by anti-abortion groups that directs the U.S. Food and Drug Administration (FDA) to withdraw its approval of mifepristone — a widely used drug used in medication abortion that’s been around for decades.?

“I think that women need to pick up their guns and take to the streets, and I’m serious. This is a crusade against women,” Derzis said.

A broad lawsuit that leaves room for questions

Medication abortions account for over half of all abortions in the United States, according to the research group Guttmacher Institute. A ruling in favor of the anti-abortion groups would not only make legal abortion more challenging, it would also erase some of the limited options left for people in states where there are strict abortion bans. These restrictions are most prominent across the southeastern United States, where maternal health care deserts are growing.?

The likely immediate impact would be that manufacturers would not be allowed to ship mifepristone anywhere in the United States, and providers would no longer be able to prescribe it. It’s still unclear what could happen with misoprostol, a drug that’s used in medication abortion as well as to treat ulcers.

The typical regimen used in medication abortion involves the use of mifepristone and misoprostol, and has been prescribed by doctors since the 2000s.?

Elizabeth Nash, principal policy associate at Guttmacher, says it’s likely that only misoprostol would be used for medication abortions — which Nash says has been done in other countries. But she says, the issue is that the lawsuit is broad in some areas, so there are still a lot of unknowns.?

“How many providers would switch to a misoprostol regimen? Not every provider would do that. Secondly, it’s unclear how patients would feel about using a misoprostol-only regimen especially because it has a higher dosage. They may be asking for more procedural abortions and that may make it harder because in-clinic abortion takes more time and resources for clinic staff,” Nash said.

Erik Baptist, senior counsel with the Alliance Defending Freedom, one of the groups that filed the lawsuit, said the lawsuit also asks the FDA to ban the use of misoprostol in medication abortion.?

“This lawsuit focused on the FDA’s approval of both mifepristone and misoprostol for its use in medication abortion. Whether a doctor could approve the use of these drugs off-label is not in the scope of this lawsuit,” he said. “I think it’s important to note that this lawsuit doesn’t target the use of [misoprostol] for benign issues such as Cushing’s disease or gastric ulcers.”?

The plaintiffs argue that the FDA did not follow protocol to evaluate whether these drugs were safe to be prescribed for medication abortion. Although, numerous studies have shown the regimen to be safe and effective.

“We will evaluate the court’s decision no matter how he may rule and determine what to do from there. We are currently focused on prevailing at the district court,” Baptist said.?

Clinics strapped to provide care, patients with fewer options

While it’s still unclear what could happen after the ruling, what is known is that people in abortion restricted states who used to go to clinics like the Pink House in Jackson are already having a tougher time seeking legal abortion.

“People are still needing and wanting abortion services. It’s just making it harder for Mississippians. It’s more expensive having to travel farther and take longer periods off of work. Some folks have had to fly to either Florida and New York. Some of these people are experiencing their first time being on a plane,” said Michelle Colón, executive director of Sisters Helping Every Woman Rise and Organize (SHERo), an abortion-rights organization that helps connect people of color to legal abortion services.?

In Florida, abortion is illegal after 15 weeks, although soon that could be reduced. In New York, that timeframe is through viability of a fetus, which is about 24 weeks of pregnancy.

Clinics in northern states are already feeling the pressure of the increased demand, said Mara Pliskin, patient navigation manager at Planned Parenthood in Illinois.?

“We’re in the trenches. We are doing the best we can and have systems in place to get scheduled as fast as we can and get them here,” Pliskin said. “We hear patients say, ‘I don’t know how to make this happen.’… We’ve definitely seen an increase in patients from the South — Louisiana, Mississippi, Tennessee, Florida, all of these states.”

Pliskin says many patients are facing dangerous situations, especially if they are in states where they have to be mindful of confidentiality or dealing with issues like intimate partner violence.?

Pliskin said that like many abortion clinics around the country, clinics in Illinois have long waitlists and resources are stretched. And, those waitlists will likely get longer if medication abortion becomes restricted, as more patients will opt for the surgical procedure.?

In fact, data from Planned Parenthood Illinois shows that for patients from Louisiana, Mississippi, Alabama, Georgia, and Florida, 38% had a medication abortion and 62% had an in-clinic procedure between Nov. 1, 2022? to Feb. 28, 2023. Meanwhile, for the overall abortion population at that clinic in the same time period, 54% had medication abortion and 46% had an in-clinic abortion for the same time period.

“We will continue to offer medication abortion with misoprostol. There is already a method for it. The only thing is that it will take longer — it’s more medication over a longer period of time and it just makes it that much more difficult for people who travel,” Pliskin said. “That means patients will have to stay in Illinois longer … before they can return home to a state where it’s illegal or restricted.”?

Even when it comes to telehealth, Pliskin says the patient still has to come to Illinois when they are actually taking the medication. That means patients will also have to spend more money and time, adding to the emotional toll and financial strain they may be experiencing, said Colón. In turn, that makes it more difficult for advocates too.?

“It’s put a burden on all of the abortion funds that are in partnership with supporting folks from Mississippi,” she said. “When somebody calls you and they need you at the drop of a hat … it’s hard and it’s just wrong and sad. This is torture and government sanctioned oppression. But we’re doing what we can.”?

A future of more health and legal safety risks around reproductive care?

Anti-abortion groups argue that medication abortion is unsafe. Terri Herring, leader of pro-life group Choose Life Mississippi, says womens’ lives are at risk.?

“Abortion pills without confirmation of gestational age and consultation with a physician are dangerous for women,” Herring said. “We need to continue to educate women about the dangers of abortion on both their physical and emotional health.”

Other groups say they’re prepared to help people who have no choice but to give birth.

“I think that the pro-life movement has shown that we are here for women and we will continue to support women whether they are pursuing abortion or not,” said Sarah Zagorski, a spokeswoman for Louisiana Right to Life. “Of course, there are improvements that can be made, but I think we’ve come a long way in supporting women in crisis.”?

But reproductive health care in some southern states is lacking, causing some of the highest maternal mortality rates in the country, especially for people of color. CDC data from 2020 show that while the national rate for maternal mortality is 20.4 maternal deaths per 100,000 births, the rate is 30.2 in Mississippi, 31.8 in Louisiana, and 36.2 in Alabama.

“This is about control. This is about obliterating liberation of not only women, but of marginalized Mississippians, Black and brown Mississippians, queer Mississippians, and low income, poor Mississippians,” Colón said, adding that people who aren’t able to have a child will seek abortion anyway, but that the process will be much less safe for them.?

There are also more legal risks ahead for both providers and patients in the wake of a potential ruling to limit medication abortion, said Kelsea McLain, deputy director of the Yellowhammer Fund in Alabama.?

Alabama’s abortion law is highly restrictive and criminalizes anyone that aids a person seeking an abortion, McLain said. Yellowhammer has had to effectively stop most of its abortion-related services. They can only provide information that’s already available in the media.?

“We really effectively can’t do anything since the Dobbs decision … we’ve had to lean heavily into our programs that support new parents,” said McLain.?

McLain said it’s been tough hearing from people who they aren’t able to help in specific ways. The other concern, she says, is that there’s a pre-filed bill in Alabama that could make abortion akin to homicide.?

“The abortion haver would be charged with the crime,” she said, noting that the ruling on medication abortion could open up room to investigate people who have miscarriages to see whether they used medication or they had it naturally.?

“We are unsure looking at a future where multiple forms of pregnancy loss are facing criminalization or investigation,” she said. “So people are going to need to be more clandestine and intentional about when they visit a doctor and disclose if they are pregnant.”?