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.

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“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.

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In 2023, a federal court ruled that West Virginia could ban the abortion pill, an early example of states successfully challenging FDA guidance on mifepristone access.

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.

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“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.

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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.”