They can bring all the lawsuits they want, but abortion providers have them beat.

In 2022, the Supreme Court overturned the right to legal abortion. Since then, one counterintuitive trend has emerged: Even as 19 states have enacted total or near-total abortion bans, the number of abortions provided in the U.S. each year has risen.

The reason is a confluence of advances in medical, logistical, and communication technology. During the first trimester, a pregnancy can be terminated with a series of pills. Those pills can be sent through the mail, and doctors can easily prescribe them on a video call, over the phone, or through digital forms. The expansion of telehealth services during the COVID-19 pandemic offered a way for clinicians to get abortion medication to patients in every state once Roe v. Wade fell, even in places that outlawed abortion. ­­

The future of that revolutionary advancement in reproductive health was placed in jeopardy earlier this month when the 5^th U.S. Circuit Court of Appeals issued a ruling that would have placed new limits on telehealth abortion. Abortion providers were then given a dramatic reprieve on Thursday, when the Supreme Court granted a full stay on that 5^th Circuit decision.

The future of abortion telemedicine is still in limbo, however. Though the stay will remain in effect while litigation proceeds, the Supreme Court could make a full ruling on the case in the not-too-distant future. Given the court majority’s far-right leanings, it may allow the attack on abortion telemedicine to go through. But health practitioners have come up with a powerful and easy-to-implement backup plan should the Supreme Court ultimately try to kill abortion telemedicine. Having learned over the past decade that the right will challenge any route to abortion access by any available means, they saw this attack coming and made preparations. Whatever the Supreme Court decides won’t keep patients from getting the abortion drugs they need.

At issue is an old rule that once required mifepristone, commonly known as the “abortion pill,” to be dispensed in person rather than by mail. The Food and Drug Administration paused this restriction in 2021 and permanently ended it in 2023, leading to a boom of telehealth abortion providers. But last year, Louisiana filed a suit in federal court demanding the rule’s return. The complaint argues that the state has standing to bring the lawsuit because “doctors and others are (as the Biden administration intended) sending streams of mifepristone by mail into Louisiana,” preventing officials from “protecting the lives of unborn babies” through the state’s abortion ban.

Louisiana is right about one thing: According to the Society of Family Planning, several hundred Louisiana patients get abortion pills by mail each month. They’re in good company: More than 1 in 4 abortions in the U.S. are now provided remotely. Even in states where abortion is legal and in-person clinics still exist, telehealth remains a popular option. In the first half of last year, telehealth care accounted for nearly 40 percent of abortions in Delaware and Nevada, where residents might live hours away from the closest clinic.

To a casual observer, the end of mailable mifepristone would seem to be a catastrophic development for abortion access, auguring a sharp decline in abortion rates nationwide. But that’s not how things will play out should the Supreme Court eventually bring back the in-person dispensing rule. Despite the best efforts of right-wing activists, legislators, and judges, abortion by mail will continue without interruption or delay.

According to Elisa Wells, co-founder and access director at Plan C, which educates patients on how to acquire abortion drugs, there are multiple existing ways to get mifepristone that would not be affected if the 5^th Circuit’s decision stands. “Nothing is going to stop people from accessing abortion pills by mail,” she said. “The genie is out of the bottle.”

Plan C estimates that 100,000 or more people a year—nearly 10 percent of reported abortion patients—already get their abortion medication through channels that bypass the U.S. regulatory system. Motivated by price, convenience, a desire for anonymity, or wariness of interacting with a clinician, some patients buy medication online from a number of online vendors selling drugs manufactured in India. Others engage the services of international telehealth practitioners who prescribe pills and ship them overseas. Patients can also get abortion drugs from peer-to-peer networks, like Red State Access, that provide imported abortion pills with no medical consultation or prescription needed.

Advocates and providers have spent the four years since the end of Roe building a robust infrastructure of websites, hotlines, and organizational partnerships to help people find their way to these unregulated outlets, with the knowledge that the abortion-rights landscape could shift at any moment. “We could see the political restriction of care coming, and we prepared for it,” Wells said.

There’s another reason why an in-person dispensing requirement for mifepristone will not end abortion by mail: Mifepristone is not the only abortion drug on the market. Though it is the only pill specifically FDA-approved for abortion and only abortion, it’s just one of two components of a classic medication abortion. The other, misoprostol, is just as safe and nearly as effective when used alone.

Misoprostol was initially approved by the FDA for stomach ulcers and is routinely prescribed off-label to induce labor, treat postpartum hemorrhage, and prepare the cervix for IUD insertion. This broad usage pattern makes it an unlikely target for a strict, politically motivated ban, which is why misoprostol has a long history in countries that prohibit abortion. Its efficacy as an abortifacient was first discovered in the 1980s in Brazil, where patients and pharmacists noticed a warning on the drug about the side effect of miscarriage and began using it as a work-around for the country’s abortion restrictions. Taking misoprostol alone has also become a standard treatment for unwanted pregnancies in countries where mifepristone is harder to come by.

At Carafem, a reproductive healthcare company that prescribes abortion medication via telehealth in 19 states and D.C., providers have offered the option of misoprostol-only abortions since 2020. Since then, thousands of Carafem’s medication-abortion patients have chosen to take misoprostol alone due to personal medical conditions, the lower price point, or comfort with a medication that is sold over the counter in Mexico and many other countries.

Care providers have been preparing with greater urgency for a potential restriction on mifepristone provision since 2023, when it looked like the courts might void the drug’s FDA approval. That year, anti-abortion physicians and medical groups asked a Trump-appointed federal judge in Texas to suspend the FDA approval, and the judge did so. But the Supreme Court ended up reversing the ruling, saying that the plaintiffs lacked standing because they were not personally harmed by the FDA’s mifepristone policies.

With that experience in the rearview mirror, two weekends ago, when the 5^th Circuit’s decision banned the mailing of mifepristone for a couple of days before the Supreme Court issued its stay, Carafem was able to quickly pivot to the misoprostol-only protocol for all its telehealth patients. Melissa Grant, Carafem’s chief operations officer, said the past few years of chaos in U.S. abortion regulations prepared the organization to be nimble when the need arose. Ultimately, even with a two-day court interruption to mifepristone access, abortion pills got mailed. Health providers see this scenario playing out no matter what the Supreme Court finally decides.

“It is like a giant chess game, in which we need to continue to keep trying to anticipate the next movement, and to overcome it to plan our next move,” Grant told me. The barrage of assaults on abortion since the end of Roe has “mobilized people in ways that maybe hadn’t been done before. What I have seen are more small groups of people coming together, saying, ‘We’re going to do this, no matter what.’ ”

Providers at the Massachusetts Medication Abortion Access Project, which prescribes and ships abortion pills to patients across the country, had to scramble to shift gears when they could no longer mail mifepristone while the 5^th Circuit’s decision was in effect earlier this month. Patients who had signed off on the two-drug treatment but whose pills hadn’t yet reached the post office had to be recontacted to consent to receiving misoprostol alone and reeducated on how to use it.

Learning from that experience, the organization made immediate changes to its operations. Employees modified the MAP’s consent forms, patient instructional materials, website FAQ page, and chatbot so that they now contain information on both medication protocols. If another restriction on mailing mifepristone suddenly materializes, all clients will already be prepared to receive and self-administer the alternative option.

“One of the things I was really proud about over the last two weeks, and the weekend where the 5^th Circuit’s decision was in effect, was just how resilient and how scrappy our movement was,” said Angel Foster, founder of the MAP. “We saw this real rallying by providers, by our legal colleagues, by advocates. I was really impressed by that.”

The misoprostol-only protocol has some downsides: It can be a bit more unpredictable, since it can take longer for a body to expel a pregnancy if it’s not prepped with mifepristone. The higher dosage of misoprostol required when it’s used alone can also lead to a greater incidence of benign but uncomfortable side effects like nausea and diarrhea.

But as far as second-choice options go, using misoprostol by itself is a remarkably effective alternative. Though some older clinical trials found misoprostol to be far less reliable at completing an abortion than a combination treatment, recent studies of patients self-managing their abortions with misoprostol outside of a clinical setting have seen success rates of 90 to 95 percent or higher, compared to a 98 percent success rate when it’s paired with mifepristone.

Abortion providers are also eyeing potential substitutes for mifepristone that are used for other medical purposes, which would make them harder to restrict. The candidates include methotrexate (a chemotherapy drug used for autoimmune diseases and ectopic pregnancies), letrozole (which reduces estrogen levels), and a higher-than-usual dose of ulipristal acetate, currently sold as an emergency contraceptive under the brand name Ella. Research has shown that all of these drugs can be combined with misoprostol to safely and effectively terminate a pregnancy.

No matter how the Supreme Court eventually rules on mifepristone-by-mail, clinicians and advocates are confident that it won’t be the end of the battle over abortion pills. Right-wing activists want the Trump administration to outlaw the shipment of all abortion medication—which could include misoprostol—by resurrecting the Comstock Act, an out-of-use anti-vice law from 1873 that banned sending pornography, contraceptives, and abortifacients through the mail. But Wells does not see a future in which any restriction on abortion pills can keep them from patients who need them. “There are so many routes of access right now that are not able to be stopped or regulated, at least not so far,” she said. “We believe that people will just start getting more and more creative and determined in making these medications available.”