As they await a federal decision on a potential nationwide ban on telehealth abortions, anti-abortion activists plan to push more states to require women to visit a doctor’s office, get an ultrasound or wait before they can get abortion pills.

Under its current guidelines, the U.S. Food and Drug Administration does not require in-person visits, ultrasounds or waiting periods for women seeking abortion pills. Nevertheless, 10 states without total abortion bans still require them.

One of those states is Florida. The state only allows abortion up to six weeks — which is before many women discover they are pregnant. Under state law, women must first get an ultrasound and then wait at least 24 hours before receiving pills or a procedure. By that time, they might be beyond the six weeks threshold.

“Floridians are already under a time clock,” said Lana’e Hernandez, a case manager for the Florida Access Network, an abortion fund that helps women pay for their abortions and travel to other states if they fall outside Florida’s narrow window.

“I see a lot of clients having to then travel out of state and take even more time off of work, adding another barrier to accessing care because of those laws combined.”

Medication abortion typically involves two drugs: mifepristone and misoprostol. The FDA approved the two-drug regimen in 2000 and gradually loosened restrictions as safety reviews showed a low risk of serious and life-threatening conditions. During the COVID-19 pandemic in 2021, the Biden administration suspended enforcement of the rule that patients had to take the medication in person, and the FDA officially removed that requirement in 2023.

But anti-abortion organizations and attorneys general have challenged these changes in ongoing federal lawsuits. And in 2025, activist groups successfully pressured the Trump administration’s FDA to review the safety data again.

On Wednesday, the FDA is expected to update the public on the progress of this review, though the agency is not expected to issue a final ruling on telehealth access to the pills. The Washington Sun recently reported that the Trump administration wants to delay any potentially controversial actions around abortion until after the midterm elections. The administration has also delayed multiple ongoing federal lawsuits until after the review.

Abortion rights advocates say reversing telehealth access to medication abortion would have a huge impact across the country. Medication abortions now account for about 65% of all abortions, and roughly 28% of all abortions are through telehealth, according to KFF, a health research group.

Critical elections

In statehouses, the midterm elections could determine whether more states will seek to restrict medication abortion.

Meanwhile, Democratic control of Congress could doom President Donald Trump’s nominee for FDA commissioner. During her confirmation hearing last month, nominee Heidi Overton would not say whether she would recommend changes to mifepristone regulation, but in the past she has expressed anti-abortion views and written that the medication is dangerous.

National anti-abortion leaders told Stateline they will not be satisfied if the FDA determines that mifepristone is safe and can be administered via telehealth.

“There are comorbidities that come with mifepristone, like ectopic pregnancies that need to be diagnosed prior to the actual provision of mifepristone, and right now under the FDA system, that’s not working,” said Bradley Kehr, vice president of legal affairs of Americans United for Life. “So states are stepping in to say that they have serious concerns, and they’re taking action for the safety of their citizens.”

Peer-reviewed studies overwhelmingly show a low risk of serious adverse events for medication abortions up to 10 weeks’ gestation, including via telehealth. But national anti-abortion groups have pointed to examples of coercion and non-peer-reviewed white papers to argue the risks are more significant than what the FDA has reported, and that ultrasounds should be required before the pills are administered.

Hernandez of the Florida Access Network said ultrasounds might be appropriate for women who have irregular periods or are at risk for an ectopic pregnancy, but that they should not be universally mandated by lawmakers. According to the American College of Obstetricians and Gynecologists, for patients with regular menstrual cycles and no risk factors for ectopic pregnancy, a clinical examination or ultrasound is not necessary before taking abortion pills.

“These are conversations that you should be having with your medical professional and not the government mandating you to do one thing or another,” Hernandez said. “You should be able to trust your physician to tell you whether you need an ultrasound or not to have an abortion.”

Abortion rights advocates say abortion is being singled out even as more medical care is being delivered via telehealth.

“When it comes to telehealth for abortion care specifically, a lot of those concerns, I think are coming from a place that’s really informed by abortion stigma,” said Kimya Forouzan, the principal state policy advisor of the Guttmacher Institute, a research and policy organization that supports abortion rights. “Receiving medication abortion via telehealth is not different than any other form of telehealth care.”

Existing restrictions

In addition to Florida, Alaska, Georgia, Iowa, Missouri, Nebraska, North Carolina, South Carolina, Utah and Wisconsin require ultrasounds or other in-person requirements before medication abortions. In-person requirements can include an initial in-person exam, in-person counseling, a requirement that the pills be dispensed in person or a requirement that the first dose be taken in person.

Thirteen other states (Alabama, Arkansas, Idaho, Indiana, Kentucky, Louisiana, Mississippi, North Dakota, Oklahoma, South Dakota, Tennessee, Texas and West Virginia) ban all abortions.

In Alaska, Missouri and Wisconsin, plaintiffs have challenged the laws on state constitutional grounds. Wyoming last year enacted a law requiring ultrasounds and a 48-hour waiting period before medication abortions. But a state district judge overturned the law in June, ruling that it violated a constitutional amendment protecting healthcare decisions, and that the state “offered no cogent evidence illustrating that a waiting period is necessary for any purpose.”

At the federal level, plaintiffs have argued that state regulations on abortion pills should not supersede the federal guidelines.

“The FDA sets the bar, and states don’t get to impede access to an FDA-approved medication,” said Kirsten Moore, director of the Expanding Medication Abortion Access (EMMA) Project, which tracks litigation related to medication abortion.

In an ongoing federal lawsuit over North Carolina’s restrictions, the plaintiffs argue that the state law conflicts with the FDA’s regulatory authority. A federal judge in 2024 ruled that the state could not ban the mailing of abortion pills, since federal rules allow it. But the judge upheld the state’s ultrasound requirement and its waiting period.

The case is pending appeal, with oral arguments scheduled for later this month at the 4th U.S. Circuit Court of Appeals, which last year upheld medication abortion restrictions in West Virginia, which bans all abortions and explicitly telehealth abortions. In that case, plaintiff generic mifepristone manufacturer GenBioPro argued the state’s ban violated the federal regulation of abortion pills, but the appeals court affirmed the lower court’s decision that FDA regulations did not preempt the state’s abortion ban.

Earlier this year, Iowa also enacted a law requiring abortion-inducing medication to be prescribed in person and dispensed in a medical setting.

Beaufield Berry, executive director of the Iowa Abortion Access Fund, said that since the law went into effect, her group has gotten more calls from people asking for financial help to travel out of state. She said there are two abortion clinics left in the state, both in central Iowa, making it especially difficult on people in rural areas.

“It’s really hard for some people to be able to make an appointment to go get an ultrasound, and then if they do that, then they’re running up against that six-week clock,” Berry said.

“For an in-person visit, that’s transportation, missing work, finding childcare. And in many cases, the act of having an abortion, you may not have support,” she said. “They may be underage, and so that creates even more barriers to getting an in-person meeting.”

Different strategies

Kehr of Americans United for Life said anti-abortion state lawmakers are still figuring out their individual strategies for restricting access to abortion medication. He cited the 10th Amendment, which gives states the authority through their police power to protect their citizens, as a legal justification for mandating ultrasounds or in-clinic visits before abortion pills are dispensed.

“Other states are taking different approaches, whether it’s the ultrasound provision to check for ectopic pregnancies and things like that, or the actual consideration of abuse that’s occurring,” Kehr said.

“We’ve had multiple stories of men forcing their pregnant girlfriends or wives to take mifepristone. So looking at it from an abusive perspective or a coercive perspective, states are really looking at the gamut of options under the 10th Amendment powers.”

Model legislation developed by the National Right to Life Committee, known as the Abortion Pill Provider Liability Education (APPLE) Act, and introduced this year in New Jersey and Ohio, would require abortion-pill prescribers to inform patients about the risks of the drugs, as well as her right to sue the provider if she faces complications.

The National Right to Life Committee also supports in-person visits and mandatory ultrasounds.

“Requiring a healthcare provider to confirm, locate, and date a pregnancy before prescribing a dangerous mixture of abortion-inducing drugs is a bare-minimum safety standard, and we believe it should apply in every state,” Ingrid Duran, director of state legislation for the National Right to Life Committee, wrote in an email.

Also looming in the background are interstate fights over so-called shield law providers prescribing medication virtually. Attorneys general in Alabama, Arkansas and Louisiana filed lawsuits last week targeting shield laws and in California, Massachusetts and New York, and individual doctors prescribing abortion pills to women in states with abortion bans.

“A woman can’t possibly receive fully informed consent specific to her when the dispensing provider doesn’t even know how far along she is in her pregnancy because the risk is different depending on how far along she is,” said Dr. Christina Francis, an OB-GYN based in Fort Wayne, Indiana, who is CEO of the American Association of Pro-Life Obstetricians and Gynecologists, which has opposed abortion pills since they were first approved in 2000.

“We believe that women deserve fully informed consent, and that necessarily involves an ultrasound when we’re talking about pregnancy.”

Stateline reporter Sofia Resnick can be reached at sresnick@stateline.org.

As physicians continue to navigate care for patients with complex pregnancies in states with abortion bans, a group of maternal-fetal medicine specialists has developed new guidelines to help providers in those states navigate legal risks for themselves and medical challenges for their high-risk patients. 

Maternal-fetal medicine specialists handle some of the most high-risk pregnancies, including patients with high blood pressure, diabetes, cancer, fetal anomalies or other complications. In states with abortion bans, those conditions can become even more dangerous for a patient if a doctor is unsure when they can terminate a pregnancy without potentially jeopardizing their medical license or facing criminal penalties that can include jail time.

“Individuals at high risk for pregnancy-associated morbidity and mortality have unique needs for reproductive health services, including abortion care,” the Society for Maternal-Fetal Medicine wrote in a special statement published this month. 

Ten states plus the District of Columbia allow abortion access without gestational restrictions, while 13 states ban abortion at all stages. Following the implementation of those bans since 2022, many hospital systems and clinics have offered different interpretations of how to avoid legal jeopardy under the bans and what qualifies under exceptions, leading to confusion and delays in care that have been documented in many states nationwide. 

To mitigate those problems, the guidelines encourage providers and administrators to set up referral networks across state lines, work to find agreement on what is permissible under state law and counsel patients on their options even in states with restrictions to deliver the highest-quality care. 

“We are uniquely positioned as high-risk pregnancy experts to make that case to our leaders,” said Dr. Justin Lappen, a maternal-fetal medicine specialist in Ohio who chaired the committee that developed the statement. “And a statement like this would give providers and our colleagues some confidence to be leaders in this space.”

The Society for Maternal-Fetal Medicine and the American College of Obstetricians and Gynecologists agree that access to abortion and counseling about options is the standard of care for obstetric patients, but there are conscientious exceptions for doctors who do not want to provide abortion care. 

Some doctors choose to affiliate with the American Association of Pro-Life Obstetricians and Gynecologists, and offer their own guidance about approaching complications, which still includes termination in some situations. The group is officially a partner of the Alliance Defending Freedom and several anti-abortion groups, as well as the Alliance for Hippocratic Medicine, which is the group that sued to revoke federal approval of one of two drugs used to terminate a pregnancy or treat miscarriages.

A representative from the American Association of Pro-Life Obstetricians and Gynecologists could not be reached for comment before publication.

Worse outcomes for high-risk patients

Nationwide, women in states with bans have reported difficulties receiving care when experiencing pregnancy complications. 

One of the most common emergencies occurs when a patient’s amniotic sac breaks before a fetus is viable. If left untreated, it can quickly turn into a deadly infection. The statement noted that after Texas passed Senate Bill 8 in 2021 banning abortion at an early gestation, waiting to treat patients in those medical situations dramatically increased negative health outcomes. According to research cited in the statement, complications such as blood transfusion, intensive care admission and serious infection resulted in 57% of cases, versus comparable research in states without restrictions that showed a complication rate of 33%. In all of the cases, the fetus did not survive.

Federal judge’s order allowing an Idaho doctor to perform certain abortions is put on hold

The guidance states hospitals and clinics should expand their abortion care to the extent allowed by law, and recognize maternal-fetal medicine specialists as sources of best care practices. It also instructs providers to work with legal teams in their networks to understand the federal Emergency Medical Treatment and Labor Act and when it may require abortion care, as well as encouraging training for basic termination procedures. 

Dr. David Hackney, a maternal-fetal medicine specialist in Ohio who published a book in August about navigating high-risk pregnancy care under Dobbs, said the statement will be useful for many providers nationwide.

“We don’t always focus enough on hospital administration, care and systems, but there’s always so much that can be done in those regions that is almost — if not more — important,” Hackney said.

After the Dobbs decision in June 2022, Hackney said, many individual healthcare systems didn’t know what to do when faced with certain situations where termination might be needed, and set a patchwork of policies that increased confusion for providers. But in the years since, providers and administrators in some healthcare systems have come together to reach informal agreements about what they are comfortable doing within the confines of an abortion ban.

“You have some defense if everyone has agreed to do the same thing,” he said.

When laws are unclear, he said, people will most often lean toward over-complying, which can create worse outcomes for the patient. 

“Even outside of abortion, medical care tends to work better when you have consensus and you have common best practices, even if it’s on a regional level,” he said. 

‘When they need me, they call me’

Many specialists’ cases aren’t emergencies, but rather pregnancies that put a patient at risk because of underlying health conditions, whether they existed before a pregnancy or developed during pregnancy, or late-term diagnoses of fetal anomalies that upend a wanted pregnancy. 

In those cases, the maternal-fetal organization says, patients should be told that their options include termination, even if that can’t happen in their home state.

Dr. Leilah Zahedi-Spung, a maternal-fetal medicine specialist who co-authored the special statement, moved to Colorado from Tennessee in 2023 after that state enacted a near-total abortion ban.

She said she saw firsthand how difficult it was in Tennessee to try to take care of patients without clarity around the law and without leadership that was willing or able to try to provide support. One goal of the statement is to help provide that kind of support to physicians, she said.

“We know you’re in a tough situation, we’re not blind to that. No one is blaming you for what you can and cannot do,” Zahedi-Spung said.

The society’s statement suggests that providers establish relationships with leaders within their clinical settings as well as in the community, region and state to agree on legal interpretations of abortion restrictions, particularly those who might hold leadership positions themselves. It also encourages doctors to establish referral networks locally and between states to ensure patient access.

“I have lots of people from Texas who have my phone number, and when they need me, they call me,” Zahedi-Spung said. “That is a system that works. And then those patients go back to safe providers who can take care of them.”  

Stateline reporter Kelcie Moseley-Morris can be reached at kmoseley@stateline.org.