The Food and Drug Administration claimed Rebecca Gomperts was violating federal law for operating Aidaccess.org: Through the site, Gomperts prescribes the abortion medications mifepristone and misoprostol to U.S. residents who receive the pills by mail, which allows them to end their pregnancies at home. In doing so, the FDA said , Gomperts poses “an inherent risk to consumers who purchase those products.” The agency also accused Gomperts of flouting the decades-long FDA restrictions on mifepristone , which require healthcare providers to administer the drug in person, at a clinic or hospital, making it illegal to sell the drug online or in pharmacies.

After consulting a lawyer about the FDA’s notice, Gomperts decided to continue running Aid Access: Knowing so many people rely on her services, she couldn’t imagine shuttering the site. Besides—the way Gomperts sees it, she’s not breaking any rules.

Roughly 21,000 women requested abortion medication during Aid Access’s first year, according to University of Texas assistant professor Abigail Aiken, and somewhere between a third and a half of those requests resulted in Gomperts writing prescriptions for pills. The vast majority of the inquiries came from people living in states that have heavily restricted abortion access, like Alabama, Georgia, and Mississippi. But even those who live in states less hostile to abortion might feel the need to seek out Gomperts’ services: As of 2014 , 90 percent of counties had no abortion clinic, and 39 percent of women of reproductive age lived in one of those counties. For an increasing number of people, Aid Access represents one of extremely few options for accessing an abortion early in pregnancy.

Gomperts launched Aid Access in March 2018 because she saw “a need.” More American women were requesting pills from Women on Web —the international abortion pill site she launched in 2006—and so she thought it made sense to establish a sister site that served the U.S. And as threats to Roe v. Wade steadily mounted, it became clear to Gomperts that the state of abortion access in the U.S. was dire.

Under these conditions, advocates say the FDA’s decision to ignore the scientific consensus around mifepristone is inherently political. They argue that to continue restricting the use of the drug means siding with the anti-abortion camp. And indeed, the FDA’s cease and desist letter to Gomperts was met with praise from more than 100 anti-choice members of Congress.

In a future where an overturned or significantly weakened Roe v. Wade allows states to ban abortion , it's conceivable that most abortions that take place outside of the medical system will involve buying pills online . But as Aiken’s data shows, it’s also how an increasing number of people are accessing abortion in our fearful present: Even with Roe in effect, decades of anti-choice lawmaking have made the right to an abortion little more than a concept for millions of Americans, particularly people of color, low-income people, and people who live in rural areas.

Gomperts isn’t alone in her war with the FDA. Following a barrage of abortion ban legislation , doctors and reproductive health advocates have been escalating calls for the agency to lift the nearly 20-year-old restrictions on mifepristone that make services like Gomperts’ illegal. They say it would significantly expand access to abortion, and more accurately reflect the growing body of research that shows mifepristone and misoprostol are overwhelmingly safe and effective , even when administered outside of a traditional clinic setting.

"I sincerely believe there is a human right here to be defended,” she said. “What I’m doing is in accordance with all the human rights agreements that exist, as well as the U.S. Constitution.”

“The FDA is over-regulating medication abortion at a time when we’re seeing increased barriers to abortion care, including efforts to ban abortion outright,” said Andrea Miller, the president of the National Institute for Reproductive Health (NIRH). “We’re concerned that the FDA is playing into political gamesmanship.”

The FDA’s restrictions on mifepristone went into effect the moment the drug was approved in 2000. Jane Henney, the FDA commissioner at the time, said the restrictions—which later became known as the Risk Evaluation and Mitigation Strategy, or REMS—made it possible for the agency to approve the drug in the first place. The only clinical data on mifepristone in the late 1990s came from Europe, and though it had been used there for decades, FDA officials weren’t sure that the drug's safety profile overseas would hold if it came to the U.S.

Henney said that requiring mifepristone to be administered by a licensed medical professional meant the agency could closely monitor the use of the drug, and collect its own safety data.

“Ironically, we implemented the restrictions to make the drug available,” Henney said. “But we also wanted to make sure there would be extensive record-keeping: There needed to be a way to gather evidence about how the drug was being used in the U.S.”

For almost two decades now, doctors in the U.S. have been prescribing mifepristone in combination with misoprostol to end pregnancies up to 10 weeks along, a procedure known as medication abortion. Patients first take mifepristone, which stops the pregnancy from progressing, and follow up with misoprostol, which effectively prompts a miscarriage. According to the Centers for Disease Control and Prevention, medication abortion made up about 25 percent of all U.S. abortions in 2015. In France and the United Kingdom, which don’t have the same restrictions on mifepristone as the U.S., the rate of medication abortion is as high as 90 percent. Though the drug can have serious side effects like excessive bleeding and infection, research shows these outcomes are rare: A 2015 study showed that the rate of hospitalization as a result of medication abortion was between 0.01 and 0.03 percent.

If the FDA chose to reevaluate its mifepristone regulations, it wouldn’t be the first time. The administration revised its guidelines for the drug in 2016 after approving an application from the company that markets Mifeprex, brand-name mifepristone. Based on the company’s recommendations, the FDA made changes to the dosage, the way it's taken, and the recommended length of time people should wait before taking the second medication. Crucially, the FDA also removed the requirement that misoprostol be administered at a clinic or hospital, but left the restriction on the books for mifepristone.