For most of the almost 50 years since the Roe v Wade Supreme Court decision legalized abortion nationwide, clinics have been the focus of the battle over abortion rights.
Protesters gather outside on sidewalks. And Republican state lawmakers try to regulate what happens inside — through laws restricting which healthcare providers can perform abortions, the kind of counseling required and which procedures are allowed.
But now, more than half of abortions are taking place with pills.
"For a lot of people, having the option of having an abortion in the privacy and comfort of their own home is appealing," said Rachel K. Jones, a research scientist with the Guttmacher Institute, which supports abortion rights.
According to data released by Guttmacher earlier this year, abortion pills – not surgical procedures – accounted for 54 percent of abortions in 2020. That makes medication abortion the dominant choice in the United States for the first time since the Food and Drug Administration approved an abortion pill, mifepristone, more than 20 years ago. It's part of a two-drug protocol approved to terminate pregnancies up to 10 weeks gestation. That protocol also is prescribed to manage some miscarriages.
During the pandemic, the FDA relaxed rules so that the tightly regulated drug mifepristone could be obtained through telehealth appointments and mail-order pharmacies, rather than in person. That made it easier for patients in some states to get a medication abortion at home. The Biden administration recently made those changes permanent.
Now, Republican lawmakers in several states are pushing back.
In South Dakota, Gov. Kristi Noem recently signed legislation designed to restrict access to the drugs.
Already, more than a dozen states restrict limit the use of telemedicine to provide abortion pills. And this year, Planned Parenthood says new restrictions have been introduced in two dozen states, some of which would ban the pills altogether if Roe v Wade is overturned.
In Georgia, Republican state Sen. Bruce Thompson sponsored SB 456, a bill banning abortion pill delivery by mail and requiring doctors to examine patients in person before prescribing them. During floor debate, Thompson said his bill was intended "to protect the cherished doctor-patient relationship."
But that position is at odds with that of major medical groups, including the American College of Obstetricians and Gynecologists and the American Medical Association, who've long supported easing access to the pills and called for lifting the in-person dispensing requirement.
Thompson opposes abortion rights, but he claims this bill is all about patient safety.
"Why would we not do everything within our power to protect women's health and safety during this difficult time in their lives?" he said.
But opponents say the bill would make patients less safe. Several lawmakers noted that Georgia is among the states with the highest rates of maternal mortality – and that those death rates are dramatically higher for Black women.
State Sen. Kim Jackson, a Democrat, noted that many people, particularly in rural areas, lack access to pregnancy care.
"What's really cruel about this bill is that those who are already the most vulnerable are the ones who are most likely to be burned by this injustice," Jackson said. "People who are poor, people who live in rural communities. People with disabilities, and people of color."
The bill passed Georgia's state senate on March 1 and is awaiting a vote in the House.
"As soon as the FDA made medication abortion more accessible, Georgia pretty much turned around and was like, 'No, we actually want to make it really difficult for people to get one,'" said K. Agbebiyi, a Georgia-based advocate with the reproductive rights group URGE, which is fighting the bill.
Agbebiyi said medication abortion could become the only option for a growing number of people in states where clinics are few and far between because of abortion restrictions.
"We know, and our opponents know, that medication abortion is going to grow in popularity if Roe is overturned," Agbebiyi said. "And that's precisely why they're trying to put as many barriers in place as possible."
It's more difficult to put up barriers on the internet, where abortion pills are available through mail-order pharmacies and other groups.
Ushma Upadhyay, a reproductive health researcher at the University of California, San Francisco, warned that if states try to block access to abortion pills, patients will find them online without a doctor's help.
"That is what I'm concerned about," she said. "It is extremely safe, but all patients should have the access to clinical support if they need it, if they have questions about how to take it, or whether what's happening is normal."
Meanwhile, some states are trying to make access to medication abortion easier. A bill moving forward in Delaware would allow a wider array of healthcare providers to prescribe the pills to their patients.