Executive Summary

Women’s health goes way beyond just reproductive and gynecological care—it's a whole spectrum of physical and mental health issues that are vital for overall well-being. In this whitepaper, we're diving into the bigger picture of women's health. We’ll touch on everything from heart health and bone health to autoimmune diseases, mental health, and more. By breaking down these areas, we aim to bust the myth that women’s health is only about having children and shine a light on why we need more research and funding in these often overlooked areas.

We also dig into the serious disparities in maternal health, especially for Black, American Indian, Alaska Native, and rural women, and explore how investing in women’s health isn't just the right thing to do—it’s a huge economic opportunity. With the FemTech market on the rise and more public funding coming in, there's a promising shift toward a more inclusive approach to women’s health. But we still have a long way to go to close the gaps and make sure all women get the care they deserve.

And let’s not forget the policy side of things. The upcoming 2024 election could significantly shape the future of women’s health policy. Depending on the outcome, we could see either a continuation of the current progress or a rollback of essential healthcare services and research funding. Advocating for policies that support comprehensive women’s health research, improve access to care, and create new financing models is crucial for making lasting improvements. By focusing on these areas, we can address the vast healthcare needs of women and unlock significant economic potential, ultimately enhancing the quality of life on a global scale.

Part 1: Beyond Reproductive and Gynecological Care

Women’s Health encompasses much more than just reproductive and gynecological health.

There’s a whole lot more to it.

It includes a wide array of physical and mental aspects that are essential for overall well-being.

In this section, I'll provide an overview of women’s health, setting the stage for the next two articles in this three-part women’s health series, which will explore market trends and policy issues.

Women’s Health is More than Reproductive Health

There’s a common misconception that women’s health is solely about a woman’s ability to have children. While this notion may be more of an outdated dogma than a misconception, it persists today. Why? Largely driven by a lack of funding and research into the broader facets of women’s health.

Recognizing that women comprise more than half the population and are uniquely affected by a wide range of conditions, from reproductive health to cardiovascular health, underscores the urgent need for more attention and investment. Here is a more comprehensive picture of women’s health:

• Bone Health: 80% of those with osteoporosis are women.

• Cardiovascular Health: to start, heart disease is the leading cause of death for women in the U.S. More specifically, though, conditions like preeclampsia increase the lifetime risk for cardiovascular disease. Preeclampsia is a pregnancy-related condition characterized by hypertension and end-organ damage.

• Oncological Health: Women are uniquely affected by uterine, cervical, and ovarian cancer. These cancers haven’t fully benefited from the treatment progress seen in non-gynecological cancers (e.g., advancements in genetics and immunology).

• Autoimmune Diseases: Women make up 75% of all Americans with autoimmune disorders.

• Metabolic Health: Polycystic ovary syndrome (PCOS) is one of the most common metabolic disorders in women and is the leading cause of anovulatory infertility. The long-term health impacts of PCOS remain largely unknown due to a lack of research.

• Gynecological Health: Uterine fibroids are the most common benign pelvic tumors in women, and when symptomatic, they significantly reduce quality of life. Additionally, endometriosis, affecting 10% of women, causes severe, life-impacting pain. The mainstay treatment is merely symptom management.

• Reproductive Health: Infertility remains a significant problem for many women, and maternal morbidity and mortality, as I’ll discuss in the next section, remain high.

• Brain Health: Nearly two-thirds of those with Alzheimer’s disease are women.

To visualize these diverse aspects of women’s health, Springboard Enterprises’ Women’s Health Innovation Program produced their Framework of Women’s Health, highlighting the various dimensions of women's health:

Women’s Health Research

As I hinted at above, the failure to invest adequately in research focused on sex-specific biology has delayed progress in fully understanding the basic pathophysiology that drives conditions unique to women.

In 2018, only 10% of NIH research funding was allocated to women's health research. Additionally, funding for research on reproductive-related conditions like preeclampsia, endometriosis, and fibroids is channeled through the National Institute of Child Health and Development (NICHD), which primarily focuses on childhood development and health. Unsurprisingly, only 8% of NICHD’s budget is spent on women’s health.

This lack of funding is a significant reason why the exact mechanism behind endometriosis remains largely unknown. Without a clear understanding of the mechanism, precise treatment cannot be administered, leaving women burdened by the disease.

Maternal Health and the Disparities that Persist

Maternal health receives significant attention since disparities in health outcomes in the U.S. are far from ideal. The maternal mortality rate for Black women remains more than 2.5 times higher than that of white women and nearly 4 times higher than that of Asian women. For American Indian and Alaska Native women, the numbers aren’t much better—the maternal mortality rate is 2 times higher than white women. Despite increased awareness of these disparities, they have not improved much over the years.

Overall, maternal mortality remains high in the U.S. The most recent data show an average maternal mortality rate of 22.3 deaths per 100,000 live births, which is substantially higher than peer countries. I should mention that one study published recently suggested the CDC’s maternal mortality data are overestimates, rooted in misclassifications of maternal deaths. The authors estimate the maternal mortality rate is closer to 10 deaths per 100,000 live births. However, this number is still higher than peer nations, and racial disparities still persist. Either way, it’s estimated that 4 of 5 maternal deaths may be preventable, such as by increased access to care.

This is a big challenge, though.

Geographic disparities also exist in maternal health. Women in rural areas face decreased access to hospitals offering labor and delivery services. And the this trend of inaccessibility is only worsening. From 2011 to 2021, 267 rural hospitals shut down their obstetrics services, which is about one in four rural hospitals nationwide. Further, 63 rural hospitals shuttered their obstetric services during the pandemic alone. Poor access to maternal care only increases the risk of complications.

Dashevsky’s Dissection

In my clinical practice, I’ve seen firsthand how women’s health issues extend far beyond reproductive capabilities. Conditions such as cardiovascular disease, osteoporosis, and autoimmune disorders uniquely affect women, highlighting the need for a comprehensive approach to healthcare.

Economically, prioritizing women’s health is a moral imperative and a significant opportunity. According to a McKinsey Report, closing the women’s health gap could boost the global economy by at least $1 trillion annually by 2040. This potential is driven by fewer health conditions, extended economic capacity, and increased productivity. The report emphasizes that focusing solely on reproductive health underestimates the broader impact of gynecological and sex-specific conditions that create a higher burden for women.

It’s also crucial for both the public and private sectors to invest in advancing women's health initiatives. Policies should support women’s health research, enhance access to gender-specific care, and create incentives for new financing models (I’ll explain more of this in Part 3 of the series). For example, increasing investments in under-researched conditions like endometriosis and menopause can unlock significant market potential and improve the quality of life for millions of women.

In summary, women’s health is a multifaceted issue encompassing far more than just reproductive and gynecological health. It includes a range of physical and mental health aspects crucial for overall well-being. Despite the significant impact of conditions like cardiovascular disease, osteoporosis, and autoimmune disorders on women, there is a persistent lack of funding and research into these areas. Addressing the disparities in maternal health, particularly among Black, American Indian and Alaska Native, and rural women, remains a critical challenge. Investing in women’s health not only improves quality of life but also presents a substantial economic opportunity, potentially boosting the global economy by at least $1 trillion annually by 2040. To close the women’s health gap, a coordinated effort involving public and private sectors is essential, focusing on research, equitable healthcare, and inclusive policy-making.

Part 2: Investment Trends and Future Market Growth

Investment in women’s health has long been overlooked.

This shouldn’t surprise you.

Until recently, the mainstream view of women’s health was limited to reproductive and gynecological health. It’s now recognized that women’s health encompasses many physical and mental aspects essential for overall well-being. Consequently, private investment in women’s health is accelerating globally—but still not enough.

In this section, I’ll highlight the current state of the women’s health market (“FemTech”), dive into market predictions, and explore the societal impacts of the growing investments.

The Current State of the FemTech Market

The FemTech space is experiencing a surge in innovation and investment. VC investment in U.S. and European women’s health companies has steadily increased, from $511 million in 2018 to an estimated $1.7 billion in 2023. Unlike the broader digital health sector, which has seen a funding cycle “reset” characterized by declining investments, the FemTech market seems to be thriving.

In fact, the change in VC investment in women’s health compared to the 2018 baseline was up 314% in 2023, while overall healthcare investment was up only 28%. According to Rock Health, Q1 2024 saw seven raises for women’s health digital health companies, totaling $105 million, a significant increase from $73 million across seven deals in Q3 and Q4 of last year.

Investors are no longer focusing solely on the reproductive space but are also investing in advanced primary care and gynecology, oncology, pelvic health, and menopause. Prominent women’s health startups like Maven and Kindbody are expanding into menopause and mental healthcare. Menopause as a category received $22 million in funding in 2019, nearly tripling to $66 million in 2023. Additionally, the launch of the Wonder Women Collaborative—a collective of digital health startups addressing women’s health needs—highlights the growing interest in the space.

However, NIH funding is still lacking. The graphic below illustrates that conditions predominantly affecting women often receive significantly less funding compared to those affecting men, despite having a higher disease burden. For instance, diseases like Alzheimer’s, anxiety disorders, and breast cancer, which disproportionately affect women, show a substantial funding gap compared to male-dominated conditions like liver cancer and prostate cancer. This underfunding leads to fewer advancements in understanding and treating these conditions, perpetuating a cycle of inadequate healthcare for women.

FemTech Market Predictions

Looking ahead, the FemTech market is set for significant growth.

Market analysts predict that by 2031, the FemTech sector will reach a valuation of approximately $130 billion, driven by advancements in personalized health solutions that leverage AI and machine learning. This will be double what the market was valued at in 2021.

One of the most exciting predictions is the expansion of FemTech into untapped health domains. Beyond reproductive health, significant investments will be funneled into areas such as cardiovascular health, osteoporosis, autoimmune disorders, and mental health. This shift will improve health outcomes and open new avenues for innovation and investment.

Public sector funding for women’s health research is also expected to substantially increase. For example:

• The Novo Nordisk Foundation, Wellcome, and the Bill & Melinda Gates Foundation have already committed $300 million over three years to advance global health equity.

• President Biden signed an executive order in March, pumping money into women’s health research through the Fund for Women’s Health Research at the National Institutes of Health (NIH). The executive order will set aside $200 million in 2025 to fund new, interdisciplinary women’s health research. In the long term, President Biden urges Congress to invest $12 billion in this fund.

• The Advanced Research Projects Agency for Health (ARPA-H) Sprint for Women's Health committed $100 million to transformative research and development in women's health.

Dashevsky’s Dissection

I find the evolving FemTech landscape to be both promising and indicative of broader systemic challenges. Don’t get me wrong, the increasing investment in women’s health is a crucial step forward to address the long-standing oversight in this field. However, while the growth in private investment is commendable, it’s not enough to meet the vast and varied needs of women globally.

From a medical perspective, the broadening focus beyond reproductive and gynecological health to include cardiovascular disease, osteoporosis, autoimmune disorders, and mental health is essential. And the current trend of increased VC investment, as highlighted by the impressive growth from $511 million in 2018 to $1.7 billion in 2023, reflects a positive shift. However, the disparities between men’s and women’s startup funding are concerning. In one McKinsey report, the authors found that 11 startups focusing on erectile dysfunction raised $1.24 billion between 2019 and 2023, while 8 startups focusing on endometriosis raised $44 million.

Lastly, the notable commitments from philanthropic organizations and the executive order to boost NIH funding are positive steps, but the scale of the actual investment needs to be much larger. As I said in the prior newsletter, women represent more than half the population, but only ~11% of the NIH’s budget is allocated to women’s health research. Biden has requested Congress to approve $12 billion to fund women’s health research, but researchers will only see $200 million next year (more discussion about policy in the next section). 

In summary, the FemTech market is undergoing significant transformation and growth, driven by increased investment and a broader recognition of women's diverse health needs. While VC investments have surged from $511 million in 2018 to an estimated $1.7 billion in 2023, and new initiatives are expanding the focus beyond reproductive health, funding gaps and disparities in research support remain significant challenges. The projected market growth to $130 billion by 2031 and increased public sector funding are promising, but much more investment is needed to address the vast and varied healthcare needs of women globally.

Part 3: Shaping Policy and the 2024 Election

After covering the background of women’s health and the space’s market trends, it’s only fitting to discuss women’s health policy, which has shaped the current landscape.

What’s particularly important about women’s health policy now is the direction it may take depending on the outcome of the 2024 election in a couple of months.

In this section, I’ll cover the policy behind reproductive health, highlight key maternal health initiatives, dive into women’s health research, and briefly discuss my thoughts on the upcoming election regarding women’s health.

The Past, Present, and Future State of Reproductive Health

It’s been two years since the Supreme Court’s majority decision in the Dobbs v. Jackson’s Women Health Organization case, effectively overturning Roe v. Wade. I’ve written a timeline below of the events leading up to the decision:

The Dobbs ruling has had a ripple effect across the nation, with many states immediately adding strict abortion laws or removing abortion rights. The Guttmacher Institute has kept track of such laws. You can see the most up-to-date abortion policies map below:

Despite states enacting such restrictive policies, abortion rates increased by 11% between 2020 and 2023 (likely an underestimate, too). While we saw an 11% increase in abortions nationwide, states without total abortion bans saw a 26% increase in 2023 compared to 2020. Further, states bordering neighboring states with strict abortion bans experienced a ~40% increase in abortions during the same time period.

There are likely three reasons to explain this paradoxical increase in abortions despite restrictive measures by states.

1. Telehealth for medication abortion increased significantly after the FDA lifted in-person dispensing requirements for mifepristone during the pandemic, benefiting many, especially in rural areas.

2. Increased financial support post-Dobbs, primarily from abortion funds, has helped many in states without bans, though its sustainability is uncertain as donations have slowed.

3. State policies, including "shield laws" in 22 states and Washington, DC, have protected healthcare providers and patients from legal consequences, expanded data privacy, and increased funds for clinic security.

So, the abortion rate increased despite strict abortion laws. We’re good!

Not exactly.

Abortion access is not easy: over 170,000 traveled out of state in 2023, overcoming substantial economic and logistic challenges. Communities of color, LGBTQ+ individuals, young people, immigrants, and those with low incomes or disabilities are especially harmed by strict abortion policies. Such policies may further exacerbate inequities already seen in maternal mortality, which disproportionately affects people of color.

Lastly, there’s been a worrying trend from restricting abortion to targeting contraception and IVF. The Kaiser Family Foundation provides a great overview of how state and federal actions are shaping access to contraception, with many states adding protective policies to safeguard contraception rights. Luckily, the mifepristone case before the Supreme Court was shot down for lack of standing, but it could have impacted how the FDA approves all drugs. More troubling, though, are the pending bills in 13 states threatening IVF by considering embryos as people, posing significant risks to reproductive healthcare access.

Key Maternal Health Initiatives

Maternal health disparities in the U.S. are stark, with Black women facing a maternal mortality rate over 2.5 times higher than white women and American Indian and Alaska Native women experiencing rates twice as high. Geographic disparities also exacerbate the issue. Rural areas are seeing a decline in hospitals offering obstetric services, increasing the risk of complications and highlighting the urgent need for better access to maternal care.

So, what’s being done about maternal health?

The Biden-Harris Administration introduced the Maternal Health BluePrint earlier in his term. This comprehensive plan outlines actions to improve maternal health outcomes, reduce disparities, and enhance the overall experience of pregnancy and postpartum. Outside of Biden’s Maternal Health BluePrint, several other pieces of legislation and key initiatives were enacted or are pending enactment. Below I’ve organized key policy highlights.

Medicaid Expansion

Biden’s Blueprint aimed to permanently extend Medicaid postpartum coverage from 60 days to 12 months. During the pandemic, states could implement this extension through the American Rescue Plan Act, which provided increased Medicaid funding. However, this funding was set to expire in 2027, creating a potential postpartum insurance cliff. Thankfully, the Consolidated Appropriations Act of 2023 made this extension permanent, and nearly all states have implemented or plan to implement it. This extension is crucial as half of pregnancy-related deaths occur between one week and one year postpartum, with over 80% being preventable. Additionally, Medicaid finances around 2 out of 5 births.

Other Legislation

Black Maternal Health Momnibus Act

The Black Maternal Health Momnibus Act (great name) is a set of 13 bills aimed at tackling the maternal health crisis, particularly among Black women. Here are highlights of the act: 

• Investment in addressing social factors affecting health

• Support of community-based organizations

• Improved care for veterans

• Diversification of maternal health workforce

• Enhanced data collection

• Support for maternal mental health and substance use. 

Mamas First Act

The Mamas First Act aims to address the maternal health crisis by expanding Medicaid to cover doula and midwifery care. This legislation seeks to improve access to culturally competent, patient-centered care, reducing maternal mortality and disparities, especially for underserved communities.

Keep Obstetrics Local Act

The Keep Obstetrics Local Act is draft legislation that would address the closure of maternity units in rural and underserved areas by doing the following:

• Increasing Medicaid payment rates for labor and delivery services.

• Providing standby payments to low-volume hospitals.

• Creating payment adjustments for low birth volume hospitals.

If you recall from my prior article, 267 rural hospitals shut down their obstetrics services from 2011 to 2021, and 63 rural hospitals shuttered their obstetric services during the pandemic alone.

Maternal Mental Health

Transforming Maternal Health Model

CMS’s Transforming Maternal Health Model helps Medicaid programs develop a holistic approach to pregnancy, childbirth, and postpartum care. The model focuses on improving access to care and delivering personalized, whole-person care to address the physical, mental, and social needs of pregnant and postpartum individuals.

HHS Maternal Mental Health Task Force

The Maternal Mental Health Task Force published their National Strategy to Improve Maternal Mental Health Care. It focuses on building a robust healthcare infrastructure prioritizing perinatal mental. Key initiatives include integrating mental health into perinatal care, expanding workforce training, and enhancing support for substance use disorders during and after pregnancy.

The Substance Abuse and Mental Health Services Administration

SAMHSA is investing $27.5 million to improve behavioral health services for women. The funds will expand access to services and improve the capacity of providers to identify and address mental health conditions, substance use and gender-based violence.

Clinical Research

Women represent more than half the population, but only ~11% of the NIH’s budget is allocated to women’s health research. This shouldn’t surprise you if you read Part 2 of this women’s health series on investment and market trends.

Sure, you may point out that the government increased NIH funding for endometriosis research in 2022 to $16 million (0.04% of the NIH budget), equating to $2 per person with endometriosis per year. Crohn’s disease, on the other hand, received $90 million in the same year, equating to $130 per person with Crohn’s per year. Around 1 million Americans have Crohn’s disease, while 6 million American women have endometriosis. So, there is 6x more funding for the disease that has 6x fewer people affected. Quite the disparity!

Big picture, though, Biden signed an executive order in March, increasing women’s health research funding via the Fund for Women’s Health Research at the National Institutes of Health (NIH). The executive order will set aside $200 million in 2025 to fund new, interdisciplinary women’s health research. In the long term, President Biden urges Congress to invest $12 billion in this fund. Some areas of research that will be funded include endometriosis, menopause, the impacts of COVID-19 on women’s health, health disparities among women of color, and women’s mental health.

Women’s Health research will receive more funding through other initiatives below:

• The Novo Nordisk Foundation, Wellcome, and the Bill & Melinda Gates Foundation have already committed $300 million over three years to advance global health equity.

• The Advanced Research Projects Agency for Health (ARPA-H) Sprint for Women's Health committed $100 million to transformative research and development in women's health.

• The Menopause Research and Equity Act (House), if passed, would require the NIH to invest in menopause research, mid-life women’s health research, and finding new treatments for the symptoms of menopause.

• Advancing Menopause Care and Mid-Life Women's Health Act (Senate), if passed, would fund $25 million annually from 2025 through 2029 for research and public health activities, and $10 million annually for the same period for public health promotion, education, training programs, and awareness efforts related to menopause and mid-life women’s health.

Dashevsky’s Dissection

I’d be remiss to talk all about women’s health policy and ignore the upcoming election. So I must ask:

Is the future of women’s health hinging on the outcome of the 2024 election?

Depending on the outcome, the future of women’s health could (will) take two drastically different paths.

The Biden-Harris administration has made significant strides in expanding access to reproductive and maternal health services, emphasizing research on female-specific conditions, and ensuring equitable healthcare for women. The White House Initiative on Women’s Health Research and other progressive policies could continue to foster advancements and provide support for women’s health issues if Vice President Harris is elected.

Conversely, Trump’s previous tenure was marked by more restrictive policies on reproductive rights, which could significantly roll back the gains made in women’s health. A return to such policies might limit access to essential health services and reduce funding for important research, negatively impacting the healthcare landscape for women.

Objectively, the stakes are high, and the election outcome will profoundly influence women’s health policy.

In summary, women's health policy is at a pivotal juncture, influenced by recent Supreme Court decisions and poised for significant change depending on the 2024 election outcome. The direction of women's health policy could drastically affect access to care and research funding, making the upcoming election a critical determinant for the future of women's health in America.

Closing Remarks

As we wrap up this exploration of women's health, it's clear that we're at a pivotal moment. The advancements in FemTech, the increasing investments in women's health, and the strides made in maternal health are all incredibly promising. But we can't lose sight of the fact that much more needs to be done.

The upcoming election adds a layer of uncertainty to our progress. The policies and leadership chosen in this election will significantly impact the future of women's health, determining whether we continue on a path of improvement or face potential setbacks.

Let's stay hopeful and committed. By advocating for comprehensive research, equitable healthcare, and inclusive policies, we can ensure that women's health continues to move forward.