Before Elrod, Ho, and Wilson, Circuit Judges. Jennifer Walker Elrod, Circuit Judge: This complicated administrative law appeal concerns the regulation of mifepristone, a drug used to cause abortion. The United States Food and Drug Administration approved mifepristone for use in 2000 under the brand name Mifeprex. At the same time, FDA imposed a number of conditions de-signed to prevent the drug from causing serious medical side effects. FDA amended those conditions in 2016, generally lightening the prior protections. It then approved a generic version in 2019. And in 2021, FDA announced that it would not enforce an agency regulation requiring mifepristone to be prescribed and dispensed in person. The agency ultimately removed that re-quirement from mifepristone’s conditions for use. The subject of this appeal is those four actions: the 2000 Approval, 2016 Amendments, 2019 Generic Approval, and 2021 Non-Enforcement De-cision. They are challenged by the Alliance for Hippocratic Medicine—an association of doctors who research, teach, and advocate for ethical medical practices—several similar organizations, and several individual doctors. At bottom, the Medical Organizations and Doctors contend that FDA over-looked important safety risks in approving mifepristone and amending its re-strictions. They assert that FDA’s actions were unlawful under the Admin-istrative Procedure Act. The Organizations seek relief on behalf of their members, many of whom are OB/Gyns or emergency-room doctors. Many women face severe complications as a result of taking mifepristone. The Doctors allege that they are harmed when they treat those kinds of patients. According to the Doctors, when they treat women who are experienc-ing complications after taking mifepristone, they are required to perform or complete an abortion, or otherwise required to participate in a process that facilitates abortion. They maintain that personally conducting those proce-dures violates their sincerely held moral beliefs. The Doctors also contend that treatment of mifepristone patients diverts time and resources away from their ordinary patients, causes substantial mental and emotional distress, and exposes them to heightened malpractice risk and increased insurance costs. Seeking to prevent those alleged injuries, the Medical Organizations and Doctors moved for preliminary injunctive relief. The district court granted the motion, but rather than entering a traditional injunction, the court stayed the effective date of each of the challenged actions under 5 U.S.C. § 705. FDA appealed, as did Intervenor Danco Laboratories, LLC, the pharmaceutical company that distributes Mifeprex. After extensive briefing and oral argument, we hold that the district court’s stay order should be VACATED in part and AFFIRMED in part. We conclude that the Medical Organizations and Doctors’ claim as to the 2000 Approval is likely barred by the statute of limitations. Accordingly, that component of the district court’s order must be VACATED. This means that, until final judgment, Mifeprex will remain available to the public under the conditions for use that existed in 2016. We also VACATE the portion of the order relating to the 2019 Ge-neric Approval because the Medical Organizations and Doctors have not shown that they are injured by that particular action. The generic version of mifepristone will also be available under the same conditions as Mifeprex. We AFFIRM the components of the stay order that concern the 2016 Amendments and the 2021 Non-Enforcement Decision. Those agency ac tions—which generally loosen the protections and regulations relating to the use of mifepristone—will be stayed during the pendency of this litigation. Finally, we note that our holding is subject to the prior order of the Supreme Court, which stayed the district court’s order pending resolution of this appeal and disposition of any petition for writ of certiorari. Danco Lab’ys, LLC v. All. for Hippocratic Med., 143 S. Ct. 1075 (2023) (mem.). I. Background This case arises under the Federal Food, Drug, and Cosmetic Act and related amendments. 21 U.S.C. ch. 9. The Department of Health and Hu-man Services is charged with responsibility for implementing that law, and has delegated that obligation to FDA, its subagency. Id. § 393. The relevant events center on the particular duty of approving new drugs. The approval process begins with a new drug application. Id. § 355(a). At this stage, it is the applicant’s burden to prove that the proposed drug is safe and effective. The Act directs FDA to deny a new drug application if, among other reasons, the applicant fails to include tests and data that show that the drug “is safe for use under the conditions prescribed, recommended, or suggested in the proposed labeling”; if “any other information” before FDA tends to show that the drug is not safe; or if “there is a lack of substan-tial evidence that the drug will have the effect it purports or is represented to have under the conditions for use prescribed, recommended, or suggested in the proposed labeling thereof.” Id. § 355(d); see 21 C.F.R. § 314.125 (regula-tions expanding on those requirements). Certain new drug applications may be designated for “accelerated ap-proval.” 21 C.F.R. § 314 subpt. H. This category applies to drugs treating “serious or life-threatening illnesses” and that “provide meaningful thera-peutic benefit to patients over existing treatments.” Id. § 314.500. The reg-ulations also require FDA to impose “postmarketing restrictions” where necessary to ensure the drug is used safely. Id. § 314.520(a). Relevant here, the agency may mandate that the drug be administered at “certain facilities or [by] physicians with special training or experience,” or that “specified medical procedures” be used. Id. § 314.520(a)(1), (a)(2). FDA has explained that it will consider accelerated approval in two situations: where the agency can reliably estimate effectiveness using a “sur-rogate endpoint”; and where FDA “determines that a drug, effective to the treatment of a disease, can be used safely only if distribution or use is modi-fied or restricted.” 57 Fed. Reg. 58942, 58942 (Dec. 11, 1992). The agency has understood approval under Subpart H as also satisfying the general ap-proval conditions provided by the Food, Drug, and Cosmetic Act. See id. (“Drugs or biological products approved under these procedures will have met the requisite standards for safety and effectiveness under the [Act] . . . and, thus, will have full approval for marketing.”). In March of 1996, an entity known as the Population Council applied for FDA to approve mifepristone as a new drug, as part of a two-drug regimen designed to cause abortion.[1] The regimen works like this: First, a pregnant woman takes mifepristone, which suppresses the production of the hormone progesterone. Progesterone is needed for the pregnancy to continue; it pre-pares and maintains the uterine lining and stimulates the production of nutri-ents. After taking mifepristone, a patient takes misoprostol, which causes the uterus to cramp and expel its contents. As part of the new drug application, the Population Council relied on three clinical studies, one conducted in the United States and two conducted in France. The studies purported to show that mifepristone was effective in the majority of cases, under the conditions imposed in each study. Those conditions included: an ultrasound to verify gestational age and diagnose ec-topic pregnancies; that prescribing physicians have experience performing surgical abortions and have admitting privileges at a nearby hospital; that the testing facilities be located close to a local hospital; and a four-hour monitor-ing period after taking misoprostol. Although mifepristone was effective for most patients, the studies showed a trend of adverse events for some women. According to FDA, “sur-gical intervention” was required in 7.9% of the subjects in the American trial and 4.5% of subjects in the French trials. The reasons for surgery included heavy bleeding, infection, incomplete abortion, and ongoing pregnancy— meaning that the embryo or fetus continued to grow and develop. FDA approved the new drug application in September 2000. The let-ters that the agency sent to the Population Council explained that the ap-proval was “under Subpart H.” FDA Approval Memorandum to Population Council at 6 (Sept. 28, 2000). This was for two reasons. First, FDA under-stood Mifeprex to be a drug that treated a serious or life threatening illness. Id. (“FDA has determined that the termination of an unwanted pregnancy is a serious condition within the scope of Subpart H. The meaningful therapeu-tic benefit over existing surgical abortion is the avoidance of a surgical proce-dure.”). And second, Subpart H was required because Mifeprex could not be administered safely without imposing certain use restrictions. Id. (“Sub-part H applies when FDA concludes that a drug product shown to be effec-tive can be safely used only if distribution or use is restricted . . . .”). In order to address the safety risks discussed above, FDA imposed several safeguards. First, it required the following black-box warning: If Mifeprex results in incomplete abortion, surgical interven-tion may be necessary. Prescribers should determine in ad-vance whether they will provide such care themselves or through other providers. Prescribers should also give patients clear instructions of whom to call and what to do in the event of an emergency following administration of Mifeprex. Approval Memorandum at 2. FDA also set the following controls on the use and prescription of Mifeprex: · Only women whose pregnancies have a gestational age of forty-nine days or less are eligible; · Only physicians can prescribe Mifeprex; · All prescribing physicians must be able to assess gestational age, diagnose ectopic pregnancies, and “provide surgical intervention in cases of incomplete abortion or severe bleeding” or have arranged for another physician to provide such care; · Prescription must occur in person; and · Prescribers must report any “hospitalization, transfusion, or other serious event[] to the sponsor.” Id. at 1, 6. Finally, FDA required three doctor’s-office visits, which are sum-marized as follows. The patient first takes mifepristone at the doctor’s office. Three days later, she returns to the office to take misoprostol. Finally, the patient visits the doctor for a follow-up appointment, to determine whether the drug has successfully terminated the pregnancy and to screen for any ad-verse effects. In August of 2002, the American Association of Pro-Life Obstetri-cians and Gynecologists (a party to the instant case) and several other similar organizations filed a citizen petition, asking FDA to revoke its approval of mifepristone. See 21 C.F.R. § 10.30. The petition argued that mifepristone was not safe to use under the approved conditions. FDA reviewed the peti-tion over the next fourteen years, ultimately denying it in 2016. Two significant developments occurred in the meantime. First, in 2007, Congress amended the Food, Drug, and Cosmetic Act. See Food and Drug Administration Amendments Act of 2007, Pub. L. No. 110-85, tit. IX, § 901, 121 Stat. 823, 922–43. The amendment authorizes FDA to require a “risk evaluation and mitigation strategy” (REMS) if it determines that such a strategy is “necessary to ensure that the benefits of the drug outweigh the risks of the drug.” 21 U.S.C. § 355-1(a)(1). The Act further allowed FDA to impose use restrictions via the REMS, like physician qualifications or report-ing requirements. Id. § 355-1(f). The law also regarded all drugs approved before the Act as having an approved REMS. See Amendments Act § 909(b), 121 Stat. at 950 (“A drug that was approved before the effective date of this Act is . . . deemed to have in effect an approved risk evaluation and mitigation strategy under section 505-1 of the [Act].”). Then in 2011, FDA approved a REMS for mifepristone, imposing es-sentially the same restrictions as those FDA required when it approved Mif-eprex in 2000. The REMS included four essential parts: a general summary, medication guide, prescriber agreement, and patient agreement. The medi-cation guide explains how to use mifepristone and the risks associated with doing so. Mifepristone REMS at 4–6 (June 8, 2011). The prescriber agree-ment requires prescribers to promise to follow FDA’s restrictions. Id. at 7– 8. And the patient agreement is a form that women must sign prior to using mifepristone; it obliges a patient to confirm that she meets the conditions for using mifepristone and acknowledge the risk of adverse events. Id. at 9–10. The mifepristone REMS was later amended in several respects. But its gen-eral form—the summary, medical guide, prescriber’s agreement, and patient agreement—remains the same. In 2016, FDA addressed Mifeprex in two respects. First, it denied the 2002 citizen petition, defending Mifeprex’s safety and effectiveness as ap-proved in 2000. Second, FDA approved a supplemental new drug application by Danco. That application requested a number of amendments to Mif-eprex’s REMS that FDA described as “major” and “interrelated.” FDA Summary Review of 2016 Amendments at 5 (Mar. 29, 2016). Those changes included: · Increasing the maximum gestational age from forty-nine days to seventy days; · Allowing non-physicians to prescribe mifepristone; · Removing the requirement that the administration of miso-prostol and the subsequent follow-up appointment be con-ducted in person; · Eliminating prescribers’ obligation to report non-fatal ad-verse events; · Switching the method of administration for misoprostol from oral to buccal; and · Changing the dose of mifepristone (600 mg to 200 mg) and misoprostol (400 mcg to 800 mcg). Id. at 2, 26. FDA also pointed to a number of studies as evidence that Mif-eprex would be safe and effective despite the amendments. Id. at 5–17. Several years later, in 2019, the American Association of Pro-Life Ob-stetricians and Gynecologists and American College of Pediatricians filed a citizen petition challenging the 2016 Amendments. The petition generally requested that FDA restore the restrictions it imposed in 2000. Separately, in April of 2019, FDA approved an “abbreviated new drug application” by GenBioPro, Inc. for a generic version of mifepristone. To assess whether the drug was safe, the agency relied on the same data that it had relied upon for the 2000 Approval and 2016 Amendments regarding Mifeprex. FDA then took several notable steps in 2021. In April, it announced that, in connection with the COVID-19 pandemic, the agency would not en-force the in-person dispensing requirement. Effectively, this allowed mife-pristone to be prescribed remotely and sent via mail. [FDA] intends to exercise enforcement discretion during the COVID-19 [pandemic] with respect to the in-person dispens-ing requirement of the Mifepristone REMS Program, including any in-person requirements that may be related to the Patient Agreement Form. Further . . . [FDA] intends to exercise en-forcement discretion during the COVID-19 [pandemic] with respect to the dispensing of mifepristone through the mail ei-ther by or under the supervision of a certified prescriber, or through a mail-order pharmacy when such dispensing is done under the supervision of a certified prescriber. FDA Letter to American College of Obstetricians and Gynecologists at 2 (Apr. 12, 2021). Later that year, FDA stated that it would adopt the change on a permanent basis. It then amended mifepristone’s REMS (which applies to Mifeprex and the generic version) in January of 2023 to formalize the re-moval of the in-person dispensing requirement. FDA Br. at 11. Finally, in December of 2021, FDA denied the 2019 citizen petition. According to FDA, the agency “undertook a full review of the Mifepristone REMS Program” and ultimately concluded that the drug was safe to use as amended. FDA Denial Letter to American College of Obstetricians and Gy-necologists at 6 (Dec. 16, 2021). FDA specifically addressed its reasons for removing the in-person dispensing requirement. Id. at 25–36. * * * Against this background, the Medical Organizations and Doctors filed the instant complaint in district court. As relevant here, they alleged that each FDA action—the 2000 Approval, 2016 Amendments, 2019 Generic Approval, and 2021 Non-Enforcement Decision—violates the Administrative Procedure Act. Danco intervened to represent its interest as the manu-facturer and distributor of Mifeprex in the United States. GenBioPro filed an amicus brief before this court but did not intervene or otherwise participate in the litigation, either in the district court or on appeal. The Medical Organizations and Doctors filed a motion for a prelimi-nary injunction. The district court held a hearing on the matter and granted the motion in part. All. for Hippocratic Med. v. FDA, __ F. Supp. 3d __, 2023 WL 2825871 (N.D. Tex. Apr. 7, 2023). For relief, the court “stayed” the “effective date” of FDA’s actions under 5 U.S.C. § 705. FDA and Danco appealed and moved to stay the district court’s order pending appeal. A motions panel of this court stayed the district court’s or-der in part. All. for Hippocratic Med. v. FDA, No. 23-10362, 2023 WL 2913725 (5th Cir. Apr. 12, 2023). The panel stayed the portion of the district court’s order relating to the 2000 Approval but did not disturb the other components of the order—regarding the 2016 Amendments, 2019 Generic Approval, and 2021 Non-Enforcement Decision. FDA and Danco then applied to the Su-preme Court for a full stay of the district court’s order, which was granted. Danco Lab’ys, LLC v. All. for Hippocratic Med., 143 S. Ct. 1075 (2023) (mem.). The Court further provided that its stay of the district court’s order would extend through the request for a petition for certiorari, if any: The April 7, 2023 order of the United States District Court for the Northern District of Texas, case No. 2:22–cv–223, is stayed pending disposition of the appeal in the United States Court of Appeals for the Fifth Circuit and disposition of a peti-tion for a writ of certiorari, if such a writ is timely sought. Should certiorari be denied, this stay shall terminate automati-cally. In the event certiorari is granted, the stay shall terminate upon the sending down of the judgment of this Court. Id. at 1075. The parties then fully briefed the ultimate question of whether the district court erred in issuing the stay order. Over thirty amici filed sepa-rate briefs on various topics. Oral argument was held on May 17, 2023, in which each side was allowed forty minutes to present its argument, double the ordinary allotted time. We now consider the merits of the appeal. II. Standing Before considering the Medical Organizations and Doctors’ claims, we must determine whether they have standing to assert them; an injunction is always improper if the district court lacked jurisdiction. Cruz v. Abbott, 849 F.3d 594, 598–99 (5th Cir. 2017). At this stage, it is the plaintiffs’ burden to “make a ‘clear showing’ that they have standing to maintain the prelimi-nary injunction.” Barber v. Bryant, 860 F.3d 345, 352 (5th Cir. 2017) (quoting Winter v. Nat. Res. Def. Council, Inc., 555 U.S. 7, 22 (2008)). And so the Medical Organizations and Doctors must satisfy the three basic elements of standing: injury, traceability, and redressability. Lujan v. Defs. of Wildlife, 504 U.S. 555, 560 (1992). Standing in this appeal turns principally on the “injury” prong. The Medical Organizations and Doctors seek prospective relief, so they must es-tablish future injury. To do that, they must show that “the threatened injury is ‘certainly impending,’ or there is a ‘substantial risk’ that the harm will oc-cur.” Susan B. Anthony List v. Driehaus, 573 U.S. 149, 158 (2014) (quoting Clapper v. Amnesty Int’l USA, 568 U.S. 398, 414 n.5 (2013)). As those stand-ards indicate, the plaintiffs must show that the threat of future injury is suffi-ciently likely. The Supreme Court has thus rejected standing theories that rely “on a highly attenuated chain of possibilities” or that “require guess-work as to how independent decisionmakers will exercise their judgment.” Clapper, 568 U.S. at 410, 413. Even so, a “substantial risk” does not require that the threatened in- jury be “literally certain.” Id. at 414 n.5; see Lujan, 504 U.S. at 564 n.2 (ac-knowledging that imminence “is concededly a somewhat elastic concept”); Babbitt v. United Farm Workers Nat’l Union, 442 U.S. 289, 298 (1979) (re-quiring that the plaintiff “demonstrate a realistic danger of sustaining a direct injury”); Kolender v. Lawson, 461 U.S. 352, 355 n.3 (1983) (“a credible threat”); Frame v. City of Arlington, 657 F.3d 215, 235 (5th Cir. 2011) (“a suf-ficiently high degree of likelihood”). Instead, a plaintiff seeking prospective relief need only show that future injury is “fairly likely.” Crawford v. Hinds Cnty. Bd. of Supervisors, 1 F.4th 371, 376 (5th Cir. 2021); accord Arcia v. Fla. Sec’y of State, 772 F.3d 1335, 1341 (11th Cir. 2014) (“a realistic probability”). In assessing whether the threatened injury is fairly likely to occur, ev-idence of prior injury is especially probative. See Crawford, 1 F.4th at 376 (citing Los Angeles v. Lyons, 461 U.S. 95, 102 (1983)). Said another way, it “is not unduly conjectural” to use the “predictable effect” of the defendant’s prior actions as a method to predict what will happen in the future. Apple Inc. v. Vidal, 63 F.4th 1, 17 (Fed. Cir. 2023) (quoting Dep’t of Com. v. New York, 139 S. Ct. 2551, 2566 (2019)). Injuries that are “one-off” instances or “epi-sodic” in nature do not move the needle much. Crawford, 1 F.4th at 376. But where the causes that produced the first injury remain in place, past-injury evidence bears strongly “on whether there is a real and immediate threat of repeated injury.” O’Shea v. Littleton, 414 U.S. 488, 496 (1974); see Crawford, 1 F.4th at 376; accord In re Navy Chaplaincy, 697 F.3d 1171, 1176–77 (D.C. Cir. 2012) (“The prospect of future injury becomes significantly less speculative where, as here, plaintiffs have identified concrete and consistently-imple-mented policies claimed to produce such injury.”). Finally, a group of plaintiffs need not show that more than one of them is likely to be injured. “If at least one plaintiff has standing, the suit may proceed.” Biden v. Nebraska, 143 S. Ct. 2355, 2365 (2023) (citing Rumsfeld v. F. for Acad. and Institutional Rts., Inc., 547 U.S. 47, 52 n.2 (2006)). A. Associational Standing 1. Factual Predicate The Medical Organizations and Doctors chiefly rely on associational standing. That is, the organizations contend that they have standing because their members are likely to sustain injuries as a result of FDA’s actions. See Hunt v. Wash. State Apple Adv. Comm’n, 432 U.S. 333, 343 (1977). We con-clude that the Medical Organizations and Doctors have made a “clear show-ing” that their members face injury with sufficient likelihood to support en-tering a preliminary injunction. Barber, 860 F.3d at 352. The standing theory forwarded here rests on several basic premises, which are recited as follows. Mifepristone causes adverse effects for a certain percentage of the women who take it. Those adverse events are traceable to FDA because it approved the drug. And hundreds of the Medical Organiza-tions’ members are OB/Gyns or emergency-room doctors who treat women who experience severe adverse effects. The Doctors are allegedly injured when they treat mifepristone pa-tients. They offer four reasons why that is so. First, when a doctor treats a woman suffering from a mifepristone complication, he or she will often be required to perform or complete an abortion. And even if not, the doctor must participate in the medical treatment that facilitates an abortion. The Doctors allege that being made to provide this treatment conflicts with their sincerely held moral beliefs and violates their rights of conscience. Second, treating mifepristone patients imposes mental and emotional strain above what is ordinarily experienced in an emergency-room setting. Third, providing emergency treatment forces the Doctors to divert time and resources away from their ordinary patients, hampering their normal prac-tice. And fourth, the Doctors allege that mifepristone patients involve more risk of complication than the average patient, and so expose the Doctors to heightened risk of liability and increased insurance costs. The Organizations reason that, given the millions of women who take mifepristone, the number of women who experience complications from tak-ing the drug, and the high number of the Organizations’ members who treat such women, their members are likely to continue to treat women suffering complications as a result of mifepristone. For the reasons listed above, providing that treatment will injure the Doctors. Thus, the Medical Organi-zations (via their members) are likely to be injured by FDA’s actions. We first examine the evidence supporting those contentions. a. Adverse Effects FDA and Danco do not dispute that a significant percentage of women who take mifepristone experience adverse effects. From Mifeprex’s initial approval to subsequent amendments to the REMS, FDA has acknowledged that a certain fraction of patients would require surgery due to miscellaneous complications. Approval Memorandum at 1; see also 2011 Mifepristone REMS at 5 (“[A]bout 5-8 out of 100 women taking Mifeprex will need a sur-gical procedure to end the pregnancy or to stop too much bleeding.”). Sim-ilarly, as explained by the motions panel, the required patient agreement dis-closes that “the treatment will not work” in “about 2 to 7 out of 100 women” who use mifepristone. All. for Hippocratic Med., 2023 WL 2913725, at * 5. To be sure, not every woman who experiences complications will pre-sent to the emergency room or require surgery and/or some other form of urgent care. But many will. According to the most updated REMS medica-tion guide, in studies conducted in the United States, between 2.9% and 4.6% of women visited the emergency room after taking mifepristone. Mifeprex Prescribing Information at 8 tbl.2 (Jan. 2023). Some women experience es-pecially severe conditions, such as sepsis (.02%) or hospitalization relating to abortion (.04% to .06%), and some women require a blood transfusion because of heavy bleeding (.03% to .05%). Id.[2] The data FDA cited in its 2000 approval memo is similar. For the American clinical trial, surgical intervention was required for 7.9% of women (4.5% for the French studies). Approval Memorandum at 1. Of that percent-age, 1.2% of women required surgery due to heavy bleeding (.3% for France) and .12% required a blood transfusion (.11% for France). Id. FDA and Danco agree that over five million women have taken Mifeprex since it was first ap-proved. These figures show that thousands of women, and as many as hun-dreds of thousands, have experienced serious adverse effects as a result of taking the drug, and required surgery or emergency care to treat those effects. The Medical Organizations contend that their members treat women who suffer serious complications after taking mifepristone. These doctors submitted declarations testifying to their experience giving this sort of emer-gency care. For example, Dr. Christina Francis recounted an instance where a patient took mifepristone at approximately ten weeks gestation. The woman experienced serious complications and the doctor was forced to per-form a surgical abortion because the drug failed to terminate the pregnancy: [T]he patient presented back at our emergency room with heavy vaginal bleeding and unstable vital signs as a result of tak-ing chemical abortion drugs. One of my partners was able to detect a fetal heartbeat. Due to the amount of bleeding that she was experiencing and evidence of hemodynamic instability, however, my partner had no choice but to perform an emer- gency D&C. The patient needed to be hospitalized overnight for close observation after the D&C. Not only did my partner need to provide several hours of criti-cal care for this patient, but my partner also needed to call in a back-up physician to care for another critically ill patient. And because the preborn baby still had a heartbeat when the patient presented, my partner felt as though she was forced to partici-pate in something that she did not want to be a part of—com-pleting the abortion. Dr. Francis Declaration 13. Dr. Francis also testified to another example where a woman had developed an infection as a result of using mifepristone: After taking the chemical abortion drugs, [the patient] began having very heavy bleeding followed by significant abdominal pain and a fever. When I saw her in the emergency room, she had evidence of retained pregnancy tissue along with endome-tritis, an infection of the uterine lining. She also had acute kid-ney injury, with elevated creatinine. She required a dilation and curettage (D&C) surgery to finish evacuating her uterus of the remaining pregnancy tissue and hospitalization for intrave-nous (IV) antibiotics, IV hydration, and a blood transfusion. Id. 12.[3] Dr. Ingrid Skop also testified to caring for many women experienc-ing severe complications due to mifepristone: In my practice, I have cared for at least a dozen women who have required surgery to remove retained pregnancy tissue af-ter a chemical abortion. Sometimes this includes the embryo or fetus, and sometimes it is placental tissue that has not been completely expelled. I have cared for approximately five women who, after a chemical abortion, have required admis-sion for a blood transfusion or intravenous antibiotics or both. For example, in one month while covering the emergency room, my group practice admitted three women to the hospital. Of the three women admitted in one month due to chemical abortion complications, one required admission to the inten-sive care unit for sepsis and intravenous antibiotics, one re-quired a blood transfusion for hemorrhage, and one required surgical completion for the retained products of conception (i.e., the doctors had to surgically finish the abortion with a suc-tion aspiration procedure). Dr. Skop Declaration
17–18, 22. She also described one occurrence where a woman’s mifepristone prescriber did not offer surgical care in response to heavy bleeding. That, in turn, required Dr. Skop to perform the follow-up surgical procedure: In my office, I treated one young woman who had been bleeding for six weeks after she took the chemical abortion drugs given to her by a doctor at a Planned Parenthood clinic. After two follow-ups at Planned Parenthood, during which she was given additional misoprostol but not offered surgical completion, she presented to me for help. I performed a sonogram, identified a significant amount of pregnancy tissue remaining in her uterus, and performed a suction aspiration procedure to resolve her complication. Id. 23. Dr. Nancy Wozniak also described a serious complication in detail, in which the patient was at risk of bleeding to death: One of my patients, who was about nine weeks pregnant, had previously been treated by hospital staff for a pulmonary embo-lism with anti-coagulants. She was advised that she could not seek a chemical abortion because it was contraindicated due to the medications; yet the woman left the hospital and sought an abortion at Planned Parenthood of Indiana. The woman was given mifepristone by the doctor at Planned Parenthood and took the drug. The woman called an Uber for a ride home from Planned Parenthood. The woman began to experience bleeding and other adverse side effects from the mifepristone. The woman’s Uber driver did not take her home because she was so ill and instead brought her to the hospital’s emergency department. At the hospital, the woman came under my care. The woman had not yet taken the second abortion drug, misoprostol. I treated the patient for the adverse effects she suffered and told her not to take the misoprostol given to her by Planned Parenthood because of the grave risk that she could bleed out and die. The woman had a subsequent ultrasound, which showed that her unborn child was still alive. I advised the in-ternists treating this patient to avoid administering certain medications that could harm the patient and her unborn child. Dr. Wozniak Declaration 24. The risk of complications, the Medical Or-ganizations say, is only heightened in the case of ectopic pregnancy. Dr. Skop testified about the dangers of taking mifepristone under that condition: [A]pproximately 2% of pregnancies are ectopic pregnancies, implanted outside of the uterine cavity. Chemical abortion drugs will not effectually end an ectopic pregnancy because they exert their effects on the uterus, which leaves women at risk of severe harm from hemorrhage due to tubal rupture, in need of emergent surgery or potentially at risk of death. Failure to perform an ultrasound prior to prescribing abortion drugs will cause some women to remain undiagnosed and at high risk for these adverse outcomes. Dr. Skop Declaration 29; see also Dr. Barrows Declaration 18. According to the Medical Organizations and Doctors, these are exam-ples of medical cases that occur across the county. The occurrences extend not just to the declarants, they say, but to all of the Organizations’ members who are doctors. The Organizations offered testimony from representatives of the American College of Pediatricians, American Association of Pro-Life Obstetricians and Gynecologists, Christian Medical and Dental Associations, and Catholic Medical Association—each of whom explained that their mem-bership includes thousands of doctors and hundreds of OB/Gyns and emer-gency-room doctors. See Dickerson Declaration
