Project 2025 Impacts all Women’s Healthcare
Hello Friends, I’ve read through all parts of Project 2025 (P25) which concern women’s healthcare. What I found is a stark attack on all women’s healthcare, not just abortion. In this post I will break down, piece by piece, how P25 will gut obstetric and gynecologic care for women of all ages. It’s a matter of life and death for all women.
Prior to modern reproductive healthcare, 25% of women died in childbirth. Many more suffered injury to and loss of bodily function from complications of miscarriage and ectopic pregnancy, pregnancy, postpartum hemorrhage, and infection. Prior to the advent of modern gynecologic medications such as oral contraceptives and IUDs, many non-pregnant women suffered from hemorrhage and pain from gynecologic conditions such as fibroids and endometriosis, which are now easily treated with “contraceptives” or hormone-interactive medications and drug implants.
Origins of Project 2025
Project 2025 has been around in various forms for over 40 years. It is the latest iteration of the Mandate for Leadership originally put forth on behalf of Ronald Reagan by The Heritage Foundation in 1980. In all its forms it represents a right-wing wish list for downsizing the federal government, concentrating power in the presidency, and circumscribing women’s rights as well as the rights of non-white races, ethnic and gender minorities.
Project 2025 seeks to outlaw women’s healthcare language
The Forward, written by Kevin D. Roberts, states on page 4-5:
“The next conservative President must make the institutions of American civil society hard targets for woke culture warriors. This starts with deleting the terms sexual orientation and gender identity (“SOGI”), diversity, equity, and inclusion, (“DEI”), gender, gender equality, gender equity, gender awareness, gender-sensitive, abortion, reproductive health, reproductive rights, and any other term used to deprive Americans of their First Amendment rights out of every federal rule, agency regulation, contract, grant, regulation, and piece of legislation that exists.”
“Abortion”
The word “abortion” is a medical term for “miscarriage” or pregnancy loss prior to 20 weeks gestation and encompasses all stages of early pregnancy loss. This is the very language through which physicians and nurses communicate patient care issues surrounding pregnancy loss. Here are some examples of medical terms that are used in textbooks, medical journals, patient care records and day-to-day communications involving patient care:
spontaneous abortion: the spontaneous loss of pregnancy prior to 20 weeks gestation
threatened abortion: spotting in pregnancy that may culminate in spontaneous abortion; to be a “threatened abortion” a fetal heartbeat must still be present
incomplete spontaneous abortion: pregnancy loss which has begun with partial expulsion of fetal and placental tissue. Incomplete abortion can cause life-threatening hemorrhage and infection. It is considered a medical emergency when accompanied by these complications. Treatments include misoprostol (one of the “abortion drugs”) and / or a surgical procedure, suction dilation and curettage (D&C). A fetal heartbeat can be present during the entire process of an incomplete spontaneous abortion, until the complete expulsion of the pregnancy tissue. This is the type of abortion that is threatening the health of women and placing physicians at risk for jail time in states with abortions bans.
Project 2025 would outlaw the term “abortion” thus depriving physicians, nurses and other healthcare providers, healthcare educators, and medical and nursing students of the very means of communicating about early pregnancy loss.
“Reproductive Health”
The overwhelming healthcare needs of women from adolescence to menopause stem from issues concerning their reproductive organs. This involves not only pregnancy-related healthcare, but abnormal uterine bleeding, polycystic ovary disease (a disorder of ovulation), fibroid tumors of the uterus, endometriosis, vaginitis, and other diseases of the reproductive organs. Most healthcare sought by women from adolescence to menopause is due to problems with their reproductive organs. As you will see, many of the medications we use to treat these disorders will be banned by Project 2025.
“Reproductive Rights”
This is a term originated by Margaret Sanger, an obstetrical nurse, in the early 1900s as she sought to fight the Comstock Laws. Sanger pushed for the ability of women, men, boys and girls to understand how their reproductive organs work through sex education; and to be in control of their reproduction via means of contraception. She published “What Every Girl Should Know” in 1920, which offered sex education and health information consequences of the lack of such education, such as venereal diseases, incontinence, and other health disorders.
The Comstock Act, passed in 1873, defined contraceptives as “obscene and illicit” and banned the dissemination of contraceptives via mail or across state lines. It resulted in the jailing of many doctors for counseling their patients about pregnancy prevention, and journalists for writing about contraception. This law remained unchallenged until 1916 when Margaret Sanger opened up her first birth control clinic (for which she was arrested and served 30 days in jail). The contraceptive provisions of the Comstock Act were not reversed until 1935 with U.S. v. One Package.
Early methods of birth control were not very effective and often required participation of the male sexual partner. Together with Katherine McCormick, one of the early female graduates of the Massachusetts Institute of technology, Margaret Sanger advocated for the development of the birth control pill. Through the combined efforts of advocacy and funding Sanger and McCormick facilitated the invention of the first oral contraceptive by Drs. John Rock and Gregory Pincus in 1953. However, oral contraceptives were not made legal in the U.S. for the purposes of preventing pregnancy until 12 years later in 1965 with Griswold v. Connecticut.
Birth control pills (BCPs), also known as “oral contraceptives” (OCPs), are now a fundamental staple in women’s healthcare, not just for pregnancy prevention. OCPs are used widely for reducing menstrual pain and bleeding in adolescents, controlling heavy bleeding and pain due to fibroids and endometriosis, treating women with polycystic ovary disease, and and many other health conditions. In addition, other medications such as progesterone and estrogen receptor blockers have evolved to treat women’s ailments. As you will see in the following, since any of these can theoretically be “abortifacients” they could be subject to bans under Project 2025.
The Comstock Act also factored into the criminalization of abortion, which was legal up to the age of “quickening” (the perception of fetal movement, about 20-24 weeks) until the 1880s. Prior to then abortions were typically performed by midwives using herbal tinctures and other methods. However criminalization of abortion did not eliminate the practice; it merely drove it underground. Complications of unsanitary abortion, lacking modern medical protocols of surgery and antisepsis, became a widespread public health issue. By the 1960s tens of thousands of women per year were being treated for hemorrhage, sepsis, and organ injury due to non-sterile illegal abortions. Cook County Hospital in Chicago maintained a 40-bed unit just for the care of women who suffered complications from illegal septic abortions. The push for legal abortion was made by womens’ groups, physicians and nurses, and believe or not, clergy groups. Abortion up to 24 weeks gestation (fetal viability outside the womb) was finally decriminalized with Roe v. Wade in 1973.
Project 2025 seeks to define life as beginning at conception and would outlaw abortion
Project 2025 remakes the Department of Health and Human Services (DHSS) into a vehicle to define as well as prescribe women’s healthcare and creates a vehicle to surveil women, families, and their doctors and nurses via overhauling the Centers for Disease Control (CDC).
First order of business on page 450 in the introduction to the new DHSS , it defines life as beginning at conception and outlaws abortion:
“Goal #1: Protecting Life, Conscience, and Bodily Integrity. The Secretary should pursue a robust agenda to protect the fundamental right to life, protect conscience rights, and uphold bodily integrity rooted in biological realities, not ideology. From the moment of conception, every human being possesses inherent dignity and worth, and our humanity does not depend on our age, stage of development, race, or abilities. The Secretary must ensure that all HHS programs and activities are rooted in a deep respect for innocent human life from day one until naturaldeath: Abortion and euthanasia are not health care.” (page 450)
On pages 454-455 Project 2025 directs the CDC to eliminate any health program that does not conform to the “life begins at conception” dogma.
Respect for Life and Conscience. The CDC should eliminate programs and projects that do not respect human life and conscience rights and that undermine Department of Health and Human Services family formation. It should ensure that it is not promoting abortion as health care. It should fund studies into the risks and complications of abortion and ensure that it corrects and does not promote misinformation regarding the comparative health and psychological benefits of childbirth versus the health and psychological risks of intentionally taking a human life through abortion.
As I mentioned above under “incomplete abortion”, the outlawing of abortion sets up tens of thousands of women per year to be at risk for hemorrhage, infection, loss of future fertility, and emergency hysterectomy. Complications of spontaneous abortions can even result in death as in the tragic case of the Georgia woman, Candi Miller.
Since the Dobbs decision overturning Roe v. Wade and the ensuing abortion bans in over 20 states thousands of women have needlessly suffered these consequences. Many of these are just now coming to light due to a 2-year lag between the occurrence of the complications and state-level analysis by state medical boards and maternal morbidity and mortality committees.
Project 2025 further states the CDC should focus on fertility awareness based methods, rather than medically based contraception. It is signaling the CDC should revert back to the Comstock law, banning all forms of contraception.
“CDC should update its public messaging about the unsurpassed effectiveness of modern fertility awareness–based methods (FABMs) of family planning and stop publishing communications that conflate such methods with the long-eclipsed “rhythm” or “calendar” methods. CDC should fund studies exploring the evidence-based methods used in cutting-edge fertility awareness.” (page 455)
Project 2025 would endow the CDC to surveil women’s pregnancy status
Project 2025 would authorize the CDC to collect date on women’s pregnancy status via the “Ensuring Accurate and Complete Abortion Data Reporting Act of 2023”. This could lead to the jailing of the woman and anyone who aids her in obtaining an abortion, as well as healthcare providers involved in her care.
“Data Collection. The CDC’s abortion surveillance and maternity mortality reporting systems are woefully inadequate. CDC abortion data are reported by states on a voluntary basis, and California, Maryland, and New Hampshire do not submit abortion data at all. Accurate and reliable statistical data about abortion, abortion survivors, and abortion-related maternal deaths are essential to timely, reliable public health and policy analysis.
Because liberal states have now become sanctuaries for abortion tourism, HHS should use every available tool, including the cutting of funds, to ensure that every state reports exactly how many abortions take place within its borders, at what gestational age of the child, for what reason, the mother’s state of residence, and by what method. It should also ensure that statistics are separated by category: spontaneous miscarriage; treatments that incidentally result in the death of a child (such as chemotherapy); stillbirths; and induced abortion. In addition, CDC should require monitoring and reporting for complications due to abortion and every instance of children being born alive after an abortion. Moreover, abortion should be clearly defined as only those procedures that intentionally end an unborn child’s life. Miscarriage management or standard ectopic pregnancy treatments should never be conflated with abortion.
Comparisons between live births and abortion should be tracked across various demographic indicators to assess whether certain populations are targeted by abortion providers and whether better prenatal physical, mental, and social care improves infant outcomes and decreases abortion rates, especially among those who are most vulnerable.
The Ensuring Accurate and Complete Abortion Data Reporting Act of 2023 would amend title XIX of the Social Security Act and Public Health Service Act to improve the CDC’s abortion reporting mechanisms by requiring states, as a condition of federal Medicaid payments for family planning services, to report streamlined variables in a timely manner. (pp 455-456)
Although the document seems to try to carve out miscarriage and ectopic pregnancy care, the treatments for all these maladies overlap. Their statement here demonstrates a clear lack of understanding of the medical realities and treatment options for abortion, miscarriage, and ectopic pregnancy, which is exactly why politicians should not engage in the practice of medicine without a medical license. Furthermore, P25 goes on to explicitly outlaw misoprostol and mifepristone. For the unintended consequences of this, read on.
Project 2025 bans mifepristone and misoprostol
Mifepristone is a chemical that blocks progesterone receptors. It can disrupt pregnancy be preventing implantation and inhibition of the formation of the placenta. Mifepristone has applications in other areas of women’s health. Many women’s health ailments, such as uterine fibroids and endometriosis, rely on progesterone receptors gone wrong. Mifepristone and other progesterone-receptor blockers are currently approved in Europe for the treatment of fibroids and endometriosis. However, it is not available in the U.S. for these gynecologic ailments, even though it has an improved side effect profile compared to other treatments for these conditions.
Misoprostol is a prostaglandin which causes uterine contractions. It has many applications in women’s healthcare. It is used as a medical alternative to a suction D&C for treating incomplete miscarriage. It is 85% effective in this situation, producing expulsion of the pregnancy tissue, avoiding a D&C for the woman. It is very safe and has few side effects. Misoprostol is also used for elective induction of labor at term and for treating post partum hemorrhage. In fact, it is so effective at controlling postpartum hemorrhage with minimal side effects, it has supplanted 3 older medications, methergine, hemabate, and pitocin as the first-line treatment for postpartum hemorrhage.
The state of Louisiana recently classified mifepristone and misoprostol as “controlled substances”. This is throwing the care for postpartum hemorrhage in Louisiana in disarray as misoprostol is being pulled off the medication carts for management of this obstetric emergency.
Project 2025 makes the claim that “Abortion pills pose the single greatest threat to unborn children in a post-Roe world.” Project 2025 directs the FDA to ban mifepristone and misoprostol (p. 458):
“Reverse its [FDA] approval of chemical abortion drugs because the politicized approval process was illegal from the start. The FDA failed to abide by its legal obligations to protect the health, safety, and welfare of girls and women. It never studied the safety of the drugs under the labeled conditions of use, ignored the potential impacts of the hormone-blocking regimen on the developing bodies of adolescent girls, disregarded the substantial evidence that chemical abortion drugs cause more complications than surgical abortions, and eliminated necessary safeguards for pregnant girls and women who undergo this dangerous drug regimen. Furthermore, at no point in the past two decades has the FDA ever acknowledged or addressed federal laws that prohibit the distribution of abortion drugs by postal mail; to the contrary, the FDA has permitted and actively encouraged such activity.
Now that the Supreme Court has acknowledged that the Constitution contains no right to an abortion, the FDA is ethically and legally obliged to revisit and withdraw its initial approval, which was premised on pregnancy being an “illness” and abortion being “therapeutically” effective at treating this “illness.” The FDA is statutorily charged with guaranteeing the safety and efficacy of drugs and therefore should withdraw this drug that is proven to be dangerous to women and by definition fatally unsafe for unborn children.”
In the document the authors make myriad inaccurate claims about mifepristone and misoprostol including the assertion that medication abortion is more dangerous than D&C. This is patently false. There is an enormous body of scientific evidence spanning over 20 years showing that medication abortion has less risk of bleeding, uterine perforation, infection, and complications of anesthesia than a suction D&C. The same is true for the use of misoprostol in the management of incomplete abortion. Misoprostol has saved many women undergoing a spontaneous abortion from the risks of a surgical D&C.
Not only are these politicians wanting to practice medicine without a license, they wish to do so based on fabricated and inaccurate information.
Moreover, many treatments for women’s gynecologic ailments involve hormonal manipulation. It would be a short step for right-wingers from banning mifepristone, misoprostol, and oral contraceptives to banning any medication that interferes with women’s hormone receptors.
In addition to directing the FDA to ban mifepristone and misoprostol, in a section which seems internally contradictory, the authors of Project 2025 goes on to assault the provision of these drugs via mail:
“Mail-Order Abortions. Allowing mail-order abortions is a gift to the abortion industry that allows it to expand far beyond brick-and-mortar clinics and into Department of Health and Human Services pro-life states that are trying to protect women, girls, and unborn children from abortion. The FDA should therefore:
Reinstate earlier safety protocols for Mifeprex that were mostly eliminated in 2016 and apply these protocols to any generic version of mifepristone. A bare-minimum policy of limiting abortion pills to the pre-2016 policy of 49 days gestation, returning to the pre-2021 in-person dispensing requirement, and returning to requiring prescribers to report all serious adverse events, not just deaths, to the drug sponsor would increase women’s health and safety.
Address weaknesses in the current FAERS (FDA Adverse Events Reporting System). The Administration and policymakers should ensure that health care workers, particularly those in hospitals and emergency rooms, report abortion pill complications. Women who experience complications from abortion pills typically go to an emergency room, not to the abortion pill prescriber, so putting the onus of reporting on the prescriber who typically has no idea that a complication has occurred means that the FAERS is seriously undercounting adverse events. Submitting an adverse event to the database should be a quick and efficient process for busy health care practitioners.
Currently, providers report that the process is difficult and convoluted.
Implement a policy of transparency about inspections of the abortion pill’s sponsors, Danco and GenBioPro, as well as facilities that manufacture the pills. The FDA should respond to congressional requests and Freedom of Information Act (FOIA) requests about inspections, compliance, and post-marketing safety in a timely manner.
Stop promoting or approving mail-order abortions in violation of long-standing federal laws that prohibit the mailing and interstate carriage of abortion drugs.”
“Partial birth abortion” and “Infanticide”
Conservative politicians continue to shout out their ignorance by repeatedly make the claim that Ob Gyns are engaging in “Partial birth abortion” and “infanticide”.
First, there is no such procedure as “partial birth abortion”. The only thing that comes close is a “dilation and evacuation” which is a 2nd-trimester surgical procedure used to end a pregnancy due to a complication such as a birth defect, premature rupture of the membranes, infection, and other obstetric complications. D&E’s are rare. The decision of whether or not to perform a D&E is always difficult and should be between the woman and her doctor. Many young physicians today are not trained in D&E because of the stigma surrounding abortion. However, it remains an essential procedure in the armamentarium of obstetric health care and needs to remain legal.
Second, these politicians continue to assert that Ob Gyn physicians “abort babies at term” or “after the baby is born”. 85% of practicing Ob Gyns support safe and legal abortion as provided for under Roe v. Wade. However, most practicing Ob Gyns (including me) do not provide elective abortions at ANY gestation. Most of us are simply too busy. The majority of abortion care in this country is provided by qualified clinics staffed by nurses and physicians oriented to that care, not Ob Gyn physician practices.
“Aborting babies at term” is infanticide. This is illegal. These politicians have provided absolutely no proof this occurs because it simply doesn’t. In general, physicians are rule-followers. We would certainly not risk our medical licenses and jail time by performing an “abortion at term” or infanticide. To makes these claims is ludicrous and insulting to the thousands of hard-working Ob Gyns in this country, most of whom do not provide elective (non-medically indicated) abortion services.
We Ob Gyns attained 12 years of education after high school to become an Ob Gyn physician: 4 years of college, 4 years of medical school and 4 years of residency. We also passed a board certification exam (written and oral) to be legitimized by the American Board of Obstetrics and Gynecology. We must obtain a license and hospital credentials to practice medicine. We maintain that license with continuing education, maintenance of board certification, and other credentials. There is no way I or any other Ob Gyn physician would risk their livelihood to engage in “abortions at term” and infanticide.
I spent 30 years of my life providing emergency gynecology services after hours, in the middle of the night to manage complications of miscarriages and ectopic pregnancies. These are the 2 most common gynecologic emergencies. They occurred almost every time I was on call and I spent a third of the last 30 years engaged in night call to attend to these emergencies.
I call on politicians to immediately cease making unfounded accusations of Ob Gyns engaging in “abortion at term”.
Conclusions
Most women’s healthcare between adolescence and menopause revolves around pregnancy and gynecologic maladies of the reproductive organs. Many of the tools we use in managing these conditions overlap, including contraceptives, prostaglandins, and the procedure of D&C.
Abortion is healthcare because it literally is: It’s miscarriage management; it’s ectopic pregnancy management. Many of the tools we use to deal with pregnancy complications are also used for abortion. The two cannot be separated without withdrawing essential modalities for women’s healthcare.
Abortion bans and Project 2025 will gut access to women’s healthcare
Abortion bans have reduced the number of Ob Gyns in states with abortion bans and they will continue to do so. Many Ob Gyns are relocating to abortion safe states, or retiring early. Obstetric units are closing. As of 2022 36% of U.S. counties were classified as “maternity deserts” with no care providers. This figure was prior to the full impact of Dobbs and is certainly higher as of this writing. This trend will continue to increase and will be difficult to reverse.
It is also resulting in lack of proper education of trainees in the safe performance of D&C and D&E. These are essential procedures needed to manage obstetric hemorrhage and infection. Failure to adequately perform these can result in hysterectomy and death. The decline in capable providers for these procedures has and will continue to increase maternal morbidity and mortality.
With respect to women’s healthcare Project 2025 is the latest repackaging of the same agenda the right-wing has been pushing for over 40 years. Politicians are not trained in medicine. They do not understand the science, the language of disease, nor the treatment options. Politicians are not licensed to practice medicine. They need to stop.
