Entrepreneurs launched startups to provide easy access to abortion pills. Now, the Texas ruling on mifepristone might force them to pivot

On Friday, Judge Matthew J. Kacsmaryk of the northern Texas U.S. district invalidated FDA approval of mifepristone, siding with anti-abortion groups and doctors who claimed in a November lawsuit that the FDA didn’t do enough research to prove mifepristone is safe and effective. (He stayed his decision for seven days to allow for appeals; mifepristone remains on the market.) The FDA has disputed the argument, saying it has continuously reviewed the drug since granting initial approval more than 20 years ago.

That same day, a Washington State judge issued an injunction ordering the FDA to take no action that would further restrict access to mifepristone. The competing rulings will likely land the matter before the Supreme Court. 

Mifepristone, paired with another drug called misoprostol, is a common prescription regimen for medical abortions, which account for more than half of all abortions in the U.S. In recent years, demand for the pills has spawned several startups that must now contend with the contradictory rulings and a potential Supreme Court decision that could yank mifepristone from the market, upending their business models.

Initially, the Texas case seemed far-fetched to Choix CEO and founder Cindy Adam, a former nurse practitioner who launched the abortion pill startup in 2019. But conversations with abortion access activism groups made her realize that the lawsuit could force Choix to change its offerings. 

Last fall, Choix began offering “advance provision” pills—doses of mifepristone and misoprostol intended for future use. As awareness of the Texas lawsuit increased, so did customer uptake for this option. A quarter of all advance provision sales occurred in February after an early hearing in the trial. Choix is still offering the two-drug protocol today but is preparing to move to a misoprostol-only regimen should courts ultimately side with the anti-abortion groups. 

However, that switch carries consequences for both the patient and the company. 

Using only misoprostol is still effective, but takes longer and often causes more gastrointestinal issues for patients. 

“While (misoprostol-only) is an option, it is not the best option. It’s not the most effective option. And it’s not what patients need and deserve, given that they have this other option,” Adam says. 

The misoprostol-only protocol will cost Choix less, but the startup must keep the price for patients the same as the two-drug regimen to offset additional costs providers will incur as they swap the drugs, Adam says. In the future, Adam will cut the cost to reflect the lower cost of misoprostol, she says.

Kiki Freedman, cofounder and CEO of abortion pill startup Hey Jane, was originally planning to switch to misoprostol only if the Texas decision favored anti-abortion groups. But as the case dragged on, the company said on Twitter it would continue to provide the two-drug regimen until the FDA told it otherwise. 

Founded in 2021, Hey Jane has experienced rapid growth since the Dobbs decision overturned Roe v. Wade last year. It has expanded its services to Connecticut and New Jersey and now provides abortion pills by mail to eight states. Hey Jane’s monthly patients have increased 110% since Dobbs, Freedman says. 

She won’t speculate on what the Supreme Court might do and how Hey Jane will respond. With an appeal of the Texas ruling already filed in the 5th Circuit and senior executives at more than 250 pharmaceutical and biotech companies condemning the ruling, both founders remain hopeful that science will prevail. 

“This ruling and the case, in general, was a pretty clear indication of the ongoing efforts of anti-choice folks to go beyond Dobbs…The goal is clearly not limited to leaving it up to the states,” says Freedman. “We will keep doing everything we can to keep providing that safe and effective care.”

Kinsey Crowley (she/her)
kinsey.crowley@fortune.com
@kinseycrowley

The Broadsheet is Fortune’s newsletter for and about the world’s most powerful women. Subscribe here.

ALSO IN THE HEADLINES

- Behind bars. A judge has ruled that Theranos founder Elizabeth Holmes must report to prison later this month after denying her long-shot bid to remain free while she appeals her fraud conviction. She's likely to make one last request for bail to a San Francisco-based federal appeals court that she's also asked to overturn her conviction. Bloomberg

- Mothers' fight. The push to hold social media companies accountable for the harm to young people has found its new voice: moms whose children have been hurt by dangerous trends, metal health issues, or online attacks. Historically, mothers have had a hand in organizing around stricter drunk driving laws and the ongoing push for gun reform. Now, they're storming senators' offices to persuade legislators to pass guardrails for social media. Wall Street Journal

- Women left behind. India's population has grown rapidly, and the country is soon to surpass China as the world's most populated country. But employment for women fell to 25% in 2022, down from 35% in 2004. Experts say that the employment crisis and social stigma are to blame, but the decline could spell trouble for India's economic growth. Associated Press

- Backing Ukraine. Estonian Prime Minister Kaja Kallas has finalized her governing coalition that will continue to make the country one of Ukraine's most dedicated allies in the war with Russia. Kallas, whose family was part of the Soviet Union's mass deportations in the mid-20th century, has vowed to increase defense to 3% of GDP. Bloomberg

IN CASE YOU MISSED IT

- Hansberry homes. Lorraine Hansberry's family has joined more than 250 people asking for help from the nonprofit Where is My Land in regaining wealth from family property relinquished under racist policies. The playwright's father owned a real estate business, but many of his properties were lost after his death to policies that the family believes disproportionally harmed Black communities, such as urban renewal and eminent domain. The 19th

- Meet IX Shells. Fortune's April/May print issue features a cover image and NFT by artist Itzel Yard, who goes by IX Shells online. Yard started studying architectural design and computer science, but threw herself into art to heal from trauma. Her success in art and NFTs, especially as a Panamanian woman, has given her the confidence to step out of her shell. Fortune

- "Feminine energy." Dominika Kulczyk is one of the world's 337 women billionaires; she inherited her wealth from her father and Poland's former richest person Jan Kulczyk, whose investments in oil, gas, real estate, and brewing gave him a net worth of $4 billion when he died. Now, she is now working on growing her fortune. She is worth $1.9 billion after striking a deal with her brother to take full control of the failing renewable energy company Polenergia in exchange for the rest of the family assets. Forbes

ON MY RADAR

Why were two female running champions killed in Kenya? The New Yorker

The hardest decisions mothers make The Atlantic

On the "professionalism" double standard for Black women The Cut

India Amarteifio is taking the crown for Queen Charlotte: A Bridgerton Story Vogue

PARTING WORDS

“The way it gets embedded across the company is that it starts at the very top, but it also involves a very robust workforce, a volunteer army of people committed to sustainability across the company as well.”

—Microsoft’s chief sustainability officer Melanie Nakagawa on getting a big company on board with sustainability