How Impact Investing Changed in 2023

By Jessica Droste Yagan and Priya Parrish

The end of one year and the beginning of the next is naturally a time for reflection. And, wow, did 2023 have a lot to reflect on! It was a paradox. It both flew by and also seemed to last forever. It was both full of volatility and new challenges and also reinforced many things we already knew and believed. It was both heartbreaking and hopeful. We expect 2024 to be similar in many ways, and while we remain optimistic, we are also grateful that our team brings the experience necessary to manage through a variety of markets, so we can face whatever might come our way.

The venture capital and private equity markets experienced a meaningful slow down this year. After a multi-year period of significant capital inflows for funds and companies, investors slowed their pace of deployment into illiquid assets as they evaluated the changing macroeconomic environment. Companies with cash runway, or options to extend cash runway sustainably, waited to raise more capital or exit, hoping to see the market shift back in their favor. In the meantime, the muted exit market meant that fund managers slowed distributions to investors. This in turn led to investors slowing commitments to new funds. This cycle is still in play, and it shifts the negotiating power to funds with dry powder that are in a very strong position to find great companies at lower prices.

We are seeing all of the above across our firm, and have been focused on supporting our portfolio companies while remaining disciplined about deploying new capital with the capital we do have. Our team includes investors and operators that have managed through these market cycles before and know that those companies that make it through will be the leaders. We are confident that many of our companies and our funds’ companies will be the leaders not only from a financial perspective but in scaling market-driven solutions to critical social and environmental challenges. 

A big positive this year was continuing to see more investors move from talk to action and from indifference to acknowledgement regarding the impacts of their investments. Family offices and individuals continued their steady movement in this direction, often driven by younger generations taking on more power and influence, but the real shift we saw this year was from charitable foundations, whose legal responsibility it is to address social and environmental issues.
Charitable foundations have long drawn a line between their grant and investment decisions, assigning the former to drive the mission and the latter to fund it. A handful of very early leaders started decades ago in acknowledging that their endowments and investments often affected their missions, whether they wanted them to or not, and started acting intentionally to shift their investments as much as possible toward achieving those missions, or at least not working against them. As they demonstrated the possibilities of that approach over time, while continuing  to meet their fiduciary duties and financial needs, others have had the confidence to follow. Now we are starting to see them follow in larger and larger numbers.

On the down side, fewer investors of any type are willing to invest in managers without a track record, and the vast majority of impact funds as well as funds led by women or people of color are in that category (also known as emerging managers). So, while impact investing dollars continued to increase in 2023, it is almost entirely going to mega firms who are raising separate sleeves of capital to capture impact demand. We are worried about what that means for emerging managers and how it might lead the industry to backslide on its progress toward more diversity and more impact. We hope to collaborate with others to support this segment of the industry. 

Government’s role in all of this will continue to be important as well. This year, we saw the government play two notable roles in the evolution of impact investing, both generally positive. 

First, both European and US governments began to step into a gap in regulation related to impact investing. In the US, the SEC shared draft rules related to transparency marketing around ESG and impact. In Europe, the interpretation and implementation of SFDR articles 6/8/9 were in full swing. Second, the US government's decisions about what and how to impact market forces continues to affect the work we do. For example, the end of ESSER funding has affected the ability of schools to afford education tools from the types of edtech companies we invest in, while on the other hand the IRA created notable tailwinds for the clean energy transition, which was already gaining steam. 

All in all, this year has seen some major challenges and we will continue to face them and more in 2024, not least of which is political risk as 2 billion people around the world will go to the polls this year to elect their leader, including here in the United States. But, as in 2023, we believe that impact investing and intentional management of ESG factors in business will only continue to grow.

We are seeing increased sophistication of impact management and measurement even from the largest, most mainstream players, as well as multiple industry-led efforts to create alignment around what and how to report data in this space. The political backlash against ESG is not going to stop what is fundamentally a market driven movement: a demand for corporations, which are enabled and supported by governments and therefore the people, to be a net positive for those people. This is the future of capitalism and we are proud to play a role in its progression.

We are grateful to all those who partner with our team on this, including our investors, the GPs we invest in, the CEOs we invest in, and all others doing their part to make capitalism the best it can be. Happy New Year - more to come in 2024!

12 Reasons we're optimistic about 2024

In last month’s newsletter, we reflected on the fear and violence rippling around the world. Despite the year’s challenges, we are hopeful that 2024 will bring new waves of opportunity to make the world a better place. Optimism is one of our values here at Impact Engine, and one we find crucial to be intentional about, especially during trying times. As this year comes to an end and a new one begins, we are sharing some of our optimism with you, and support you to find your own.

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Ander Iruretagoyena: In times of conflict, there remains a powerful reason for optimism as exemplified by the remarkable ability of humans to unite despite differences. This was vividly demonstrated during my wedding this past October, where my Mexican family and my wife's American family came together seamlessly, transcending cultural disparities and celebrating our shared values of love and unity. The event served as a poignant reminder that, even in the face of broader societal conflicts, the fundamental human capacity for understanding and acceptance can prevail. It reflects the potential for collective harmony when individuals focus on shared humanity, fostering connections that go beyond borders, backgrounds, and divisions, ultimately paving the way for a more hopeful and inclusive future.

Anna Reilly: I am optimistic about the future for female investors and founders. While the negative statistics around investing/financing for women are often called out (and necessary to be aware of and act upon), I have been encouraged by the number and the quality of conversations I have had with both female investors and founders in the past couple of months. The women I have spoken to, or in some cases read about, are building increasingly essential, incredibly unique investment firms and companies. These interactions have ranged from a super-sharp fellow education investor’s willingness to connect after a cold outreach to hearing about a former physician’s mission to make healthcare more accessible in rural Kentucky. It is these conversations combined with my own experience as an investor, where I have been empowered by both my male and female colleagues and connections, that fuel my optimism for a more diverse future for both investing and founding.  

Cara Wood: The arts make me optimistic. I’m naturally a numbers person, numbers and processes are the way I best know how to enter the world and help the team. These things can be beautiful too, but often I discover more realities than dreams. The arts help me remember the beauty in the world when I am tempted to be overcome by grief from all of the wrongs I’d like to right. I can think back to the first time I heard Cynthia Erivo sing “I’m Here” in the musical The Color Purple, or I remember how captivated I was the first time I went to the Musee d’Orsay, or the levity and connection I felt listening to Trevor Noah’s memoir on audio book.  All these things were reprieves from the stresses I was experiencing in daily life, but more recently I have been touched and pushed to dream by the art being created within the hardships. The poems coming out of Gaza and the art I see on social media or on the walls of buildings that allow people to share their support or remembrance for people they love. These are not a step away from real life, rather they create a way through. I still hold my memories dear, but I am using this more recent art as a catalyst to keep fighting for the things I believe in and to not lose sight of beauty still being created while we work for a better future.

Chris Wu: The record setting level of participation, and the amount of new pledges, at COP28 give me hope and optimism. While certain aspects of COP can be frustrating and is not without controversy, this year’s event drew over 100K attendees and mobilized over $57B in its first four days. In particular, stories from folks that were on the ground and in the meetings, like this one from Dawn Lippert on LinkedIn, only reinforce that hope: “Momentum is built in moments. On Sunday from 10pm-1am I had 3 hours of the most electrifying climate conversations that I can remember. CEOs, investors, and leaders of major agencies seemed animated with a sense of purpose. This electric energy and quest for ambition has already influenced major decisions that will never be reported in official COP commitments.”

Jessica Droste Yagan: I’m optimistic that what we each choose to do with our time and money matters. It’s so easy to feel like whatever I do is inconsequential and will be meaningless against the giant challenges we face in the world. But then I look around and notice every single good thing, every single thing moving in the right direction is happening because of the individuals who chose to act positively. From the woman I met last week pushing her state pension toward deeper engagement with public corporations, to the industrial manufacturing company board member I spoke to last month who is pushing her board to ask questions about supply chain impacts, to my mom and her friends who decided their county of 21,000 people in rural Illinois should have an Arts Council and so started one. It all matters. That gives me the energy to wake up every day and do the things I can do to inch humanity forward - perhaps imperceptibly in the scheme of the universe, but it matters!   

Leslie Polster: I feel hopeful and optimistic about humanity. I’ve been listening to an NPR podcast called My Unsung Hero that shares short stories of simple acts of kindness that leave lifelong impressions. For example, there was a story about an English teacher’s response to a stuttering student that ended up changing that student’s life, a mother traveling through the airport with her 3 kids who was assisted by a stranger that noticed she was struggling, a trash collector going out of his way to tell a man who recently lost his mother that she was the nicest person in their route. These stories of humans helping and being kind to one another–without an expectation of receiving something in return–give me faith in the inherent goodness in human nature.

Maggie Stohler: I'm optimistic about the power of collective action. Prior to joining the Impact Engine team earlier this year, I spent four years working closely with Catholic and faith-based institutional investors who were aligning their investment portfolios with their faith values and moving more capital into social and environmentally impactful investments. I met many different communities of impact-focused investors, and their work gives me great hope about creating systems-level change. No group demonstrated the power of collective action better than the nuns. Initiatives like the Religious Communities Impact Fund, a group of 32 Catholic women’s religious congregations that allocate capital to economic justice debt and equity investments, and the Climate Solutions Fund, a group of 16 congregations of Dominican sisters who pooled together $130 million to invest in financing climate change solutions, remind me that there is transformative power in collaboration!

Priya Parrish: I believe that the success of impact investing as a movement will be largely driven by the talent behind it, and the quality I've seen come into our field this year gives me confidence in our future. This month, I finished teaching my annual impact investing course at the University of Chicago Booth School of Business, and was taken aback by the shift in students who come into business school already knowledgeable about impact investing. The rigor and creativity I saw these MBA students put into their final projects, the design of their own impact funds, grew tremendously compared to prior years. Imagine what the field will look like ~10 years from now when they are the leaders! It's true, the demand for impact investments continues to grow even in a tough fundraising year, yet the real story is the supply side of investors.

Rahul Bhide: In the backdrop of increased income and wealth inequality, as well as other sustained economic pressures, it was heartening to see the number of conversations this year focused on ‘impact’ in some shape or form across conferences and events, even in spaces that have not traditionally focused on it. 

Roger Liew: It’s been a challenging couple of years in the startup space as capital became harder to come by. I’m buoyed by the progress many of our portfolio companies have made in tough times. For example, PadSplit was featured in the New York Times by Nicolas Kristoff as “The Old New Way to Provide Cheap Housing,” and BookNook published research results that certified their literacy product as ESSA Level 1 which “represents the strongest level of evidence and, therefore, the strongest level of confidence that a strategy will work”. 

Sophia Friedman: While we are inundated with negative news cycles and so much suffering in the world, my role in health equity reminds me every day of recent breakthroughs and innovations in healthcare. 2023 saw several new product approvals in the US, offering treatments for diseases that previously had few treatment options. These include (amongst others): The approval of the first CRISPR/Cas9 gene editing therapy to target sickle cell disease - a major advancement in the field of gene therapy and a first for this disease state where there is significant unmet need and few treatment options. The first FDA approved RSV vaccine for expectant mothers aimed at protecting their unborn babies. The Alzheimer’s drug lecanemab won full FDA approval and clinical trials showed that the drug slowed cognitive decline by ~30% over 18 months. The first oral pill to treat postpartum depression became available by prescription in the United States. It’s incredible to think about the progress made this year - some have even called this the ‘golden age’ of medicine - and is inspiring to think about what new advancements might be made another year from now.

Tasha Seitz: This has been a tough year in private markets, but despite the headwinds, I remain optimistic. Having managed through several challenging economic environments during my career as an investor, I have seen well-run companies survive — and even thrive — during difficult times. I’m thankful to be surrounded by talented teammates, entrepreneurial leaders and fund managers committed to building businesses that improve economic opportunity, health equity and environmental sustainability.  They inspire me and fuel my optimism about the future!

Sector Spotlight: Environmental Sustainability Investing

Sector Spotlight is a periodic series highlighting each of the individual impact areas we invest in.

This month we sat down with Impact Engine Vice President Chris Wu to learn about his speciality, environmental sustainability investing.

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Why are you personally drawn to environmental sustainability investments?

Prior to Impact Engine, I spent the majority of my career focused at this intersection between the natural and the built environment. I studied civil & environmental engineering in college. My first job coming out of school was as a structural engineer designing buildings in New York City. I was really fortunate, my first project would end up becoming the first LEED Platinum skyscraper in the world, the Bank of America Tower at One Bryant Park. That experience went a long way towards seeding my interest in all things sustainability.

What’s an example of a recent E.S. investment we’ve made here at Impact Engine?

I’m really excited about our recent investment in a company called Circuit, which is an on-demand microtransit solution provider that uses fleets of electric vehicles specializing in pooled rides to fulfill the first/last-mile gap that's experienced by municipalities around the world.

Circuit’s last mile solution has demonstrated that it can serve as a connector to public transit systems or mass transit hubs, and has effectively addressed transit deserts in places like West Dallas. The company has strong business traction with a diverse set of customers including cities, municipal partners, private inter-city rail companies, and real estate property owners. Circuit has delivered over 5 million rides to date, and in 2021 alone they served over 650,000 riders, reduced congestion by over 1,000,000 vehicle miles traveled, and prevented 535 tons of CO2 emissions. They are able to deliver all this to cities at a much lower cost than current options. Fixed route bus systems with low ridership can cost a city over $35 per ride, whereas Circuit successfully serves Pompano Beach, FL at just $2.28 per ride. 

When you’re evaluating a potential investment in this space, what are some special aspects you consider? Things you like to see in a company?

In general, I’m typically looking for a strong mission-driven team with a compelling and differentiated product that is addressing a large social or environmental challenge, which also represents an attractive market opportunity. I really like to see a founder who is steeped firsthand in the problem they’re trying to solve, and I look for companies where the impact is baked into the core DNA of the business so that the impact scales in lock-step as their revenue grows

In the sustainability space, I think it’s particularly important to have a team who can demonstrate that they are strong at customer acquisition because they may be selling to governments, utilities, or large enterprise clients where the sales process can be very long and challenging. Another special aspect to consider is the changing regulatory landscape, and how new legislation can help open up or accelerate new markets for sustainability companies.

Are there particular challenges to investing in the environmental sustainability sector?

Climate change touches every aspect of our economy, as a result sustainability is a very broad space that can cover everything from food & ag, transportation, and energy, to the built environment and the industrial sector. So it’s important to stay up to speed on a wide range of topics, but that’s also part of what makes investing in environmental sustainability so fun! 

Looking forward, what’s got you excited in the environmental sustainability space? Big opportunities on the horizon?

It’s a really exciting time to be investing in the environmental sustainability space. There’s a confluence of different factors all converging to drive strong tailwinds, including the passage of the Inflation Reduction Act, the SEC’s proposal to require publicly traded companies to disclose climate-related financial risks, seeing that 80%+ of global GDP is now covered by net zero commitments and 20% of the world’s largest companies have adopted net zero targets, as well as consumers shifting their sentiment towards more sustainable purchasing behavior. I’ve also seen an influx of new talent entering the space, I’ve met a lot of first-time entrepreneurs who come from traditional engineering and science backgrounds and are applying their expertise to help develop novel, highly scalable solutions to some of the biggest environmental challenges we face. Taken all together, it’s a great time to be building a climate tech startup, and I look forward to supporting them.

I also think the environmental sustainability space has a big opportunity in terms of driving more equity and inclusion. Disadvantaged communities and people of color are often on the frontlines of climate change, and are disproportionately impacted by its negative effects related to health, quality of life, and economic outcomes. Climate justice is becoming more top of mind for folks in the space, as demonstrated with initiatives like Justice40 as well as the work of organizations like the Greenlining Institute and Browning the Green Space, and I look forward to seeing more progress on this topic moving forward.

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Browse our environmental investment portfolio.

The next healthcare horizon: improving maternal health through innovation and technology

By: Sophia Friedman and Gabrielle Bunney, MD 

Each year, Impact Engine selects key themes within Health Equity to focus on. These themes reflect areas with significant unmet need and high potential impact that are ripe for investment. We focus on solutions that strive to make access to healthcare more equitable to all, with a focus on populations that have historically struggled to receive equal access to care. One such area is women’s health. While women make up roughly 50% of the population, women often struggle to access healthcare services and face gender biases in healthcare settings, leading to poor health outcomes. This issue is especially acute within maternal health: maternal mortality is staggeringly high in the United States when compared to other developed countries. We wanted to better understand these trends, the systemic factors leading to inequalities in access to care, and how the private sector can play a role in addressing these challenges.

Maternal mortality, defined as deaths during pregnancy and up to 42 days postpartum, reached 23.8 per 100,000 pregnancies in the US in 2020. The US now ranks last overall among industrialized countries in terms of maternal health outcomes. While the topic of maternal mortality has often been overlooked in the US, the Supreme Court’s recent overturning of Roe v. Wade has brought more widespread attention to the issue. Some worry that the recent overturning of Roe v. Wade could worsen maternal health outcomes and exacerbate health inequalities in the US, making the need for innovation in this space all the more critical.  While the statistics are grim, women’s health, and maternal health specifically, is an area that investors are increasingly beginning to explore to fund solutions that close the gap between the US maternal mortality rate and the rest of the world. 

The medical causes of maternal mortality are multifaceted, ranging from hemorrhage, infection, hypertensive disorders, cardiac conditions and others. While some disorders are unavoidable, many complications can be addressed by providing women with early access to care. Screening and early monitoring can help detect hypertensive disorders and cardiac conditions and also reduce C-sections. However, prenatal care is not just about showing up for visits. While the US standard of prenatal care dictates that 12-14 visits are required, we know that women who are uninsured or are on Medicaid are more likely to attend less than 10 prenatal visits. This leads to the conclusion that attending more visits must therefore be better. However, our European counterparts have better maternal outcomes and average recommending nine prenatal visits, significantly fewer than the US recommendation. Therefore, impact will not only come from getting women to attend appointments, but also from examining the quality of care that is delivered in -- and between -- those visits.

  While medical causes have often been the focus, morbidity and mortality also stem from other causes, including mental health and the social determinants of health. These require a focus on multidisciplinary care, going beyond the health care provider and including those in the mental health professions, social work, dieticians, doulas, midwives and more. One argument for the success of prenatal care in Europe is that women have more social support and financial benefits, suggesting that a more integrative approach to care may be important.

Racial disparities account for a large portion of the maternal mortality rate. Black women have a much higher mortality rate when compared to women of other races in the US. Black women receive less prenatal care as they are less likely to initiate care, less likely to access timely and affordable care, and less likely to utilize care by the end of pregnancy. 

The key social factors that impact maternal health outcomes include income, lack of social support and child care, food instability and education, all of which disproportionately affect black women. While these are important drivers, a greater emphasis needs to be placed on culturally competent care. When providers understand the background of the patients they care for, it allows for them to build trust, leading to a therapeutic relationship and ultimately better care.

Rural areas are also plagued by high maternal mortality. Approximately 15% of annual US births occur in rural hospitals, and rural communities have higher maternal and infant mortality than the national average. Overall there is a shortage of providers in rural areas and births are primarily attended by a family practice physician or midwives, rather than an obstetrician-gynecologist.

It is important to note that Medicaid covers about 50-60% of rural births. Medicaid is an important source of insurance for pregnant women regardless of their location. Insurance status is often linked to employment, and women who are expecting are less likely to be employed during the year they are pregnant. Public insurance is therefore an integral factor for pregnant women. Having coverage by public insurance was associated with a lower likelihood of spending >10% of their income and reducing the economic burden on pregnant women. However, women who do not normally qualify for Medicaid lose their Medicaid insurance 60 days postpartum. Medicaid expansion is done on a state-by-state basis, and therefore solutions that can solve this gap are greatly needed, in addition to lobbying for policy change.

Maternal health is a subset of the broader women’s health and femtech¹ categories, which are experiencing significant growth. Some estimate that the women’s health market will be approximately $60 billion by 2027. Specifically, the current challenges in maternal health make this an area that is ripe for investment. In examining the landscape of digital health products addressing women’s health, approximately 19% are in maternal health. Overall, femtech investments are also rising, with increasing capital and an increasing number of deals. There was a notable increase in 2021 in the amount of VC capital that was raised – Impact Engine portfolio company Elvie raised $97M, Maven Clinic raised $110M and Flo Health raised $50M. 

Startups in women’s health have been primarily divided between devices, diagnostics, and digital solutions. We focused on digital solutions because that is our primary lens on investing in this space. Digital solutions span online community resources, telehealth, and remote monitoring. Key themes of focus within the maternal health space include:

• Software solutions that help to educate and engage women of reproductive age, specifically those who may soon become pregnant or who already are pregnant. Focusing on women who may soon become pregnant is critical, as often women have undiagnosed pre-existing conditions, and improving the health of women before they become pregnant or early on in the pregnancy is critical to improving health outcomes throughout the pregnancy and beyond. 
  

• Solutions to pair pregnant women with additional support services such as doulas, midwives, nutritionists and mental health professionals. Given current labor challenges, it will be important for these solutions to also focus on increasing the supply of such professionals, which has a dual impact of increasing economic opportunity while improving health outcomes.
  

• Remote patient monitoring solutions that can be used in the home. These solutions, some of which integrate innovative devices and hardware, can bridge gaps in care as they can aggregate data and take a woman’s vitals (e.g., weight, blood pressure, and even fetal monitoring) to monitor women between visits and escalate issues as they arise, rather than waiting for a regularly scheduled check-up. 

While point solutions can target specific parts of the patient journey, it is important to keep in mind the holistic health of the woman throughout the entire process when considering solutions in this space. We believe that the winners will be solutions that address the woman’s whole health and/or integrate with other solutions to support various social and medical factors that may affect a woman’s health throughout her pregnancy and beyond.  

The increasing number of firms entering the women’s health space is encouraging. However, many solutions that target maternal health specifically are still early-stage and therefore have yet to show the correlation between the product or service and improved maternal health outcomes. It will be important to evaluate the impact that the solutions will have as well as women’s access to these services (e.g., via insurance coverage) in order for them to make lasting change and improve health outcomes. Hard questions need to be asked: How can we change the delivery of prenatal care to reduce the burden of receiving care? How can we provide culturally competent care to women? What outcomes should we be looking at e.g., reduced C-section rates, reduced preterm birth rates, reduced NICU days? How can we provide access in rural areas without compromising the quality of care? How can we reduce the cost burden on pregnant families beyond Medicaid expansion? These are a few questions that attempt to get at the core of the disparities that pregnant women experience in our current healthcare system and should guide the evaluation of new solutions. 

¹The femtech industry refers to a range of health software and tech-enabled products to improve healthcare for women across a number of female-specific conditions.

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References:

1. https://www.commonwealthfund.org/publications/issue-briefs/2020/nov/maternal-mortality-maternity-care-us-compared-10-countries

2. Collier AY, Molina RL. Maternal Mortality in the United States: Updates on Trends, Causes, and Solutions. Neoreviews. 2019 Oct;20(10):e561-e574. doi: 10.1542/neo.20-10-e561. PMID: 31575778; PMCID: PMC7377107.

3. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm

4. https://www.americashealthrankings.org/learn/reports/2019-annual-report/international-comparison

5. Peahl AF, Smith RD, Moniz MH. Prenatal care redesign: creating flexible maternity care models through virtual care. Am J Obstet Gynecol. 2020 Sep;223(3):389.e1-389.e10. doi: 10.1016/j.ajog.2020.05.029. Epub 2020 May 17. PMID: 32425200; PMCID: PMC7231494.

6. Carter EB, Tuuli MG, Caughey AB, Odibo AO, Macones GA, Cahill AG. Number of prenatal visits and pregnancy outcomes in low-risk women. J Perinatol. 2016;36(3):178-181. doi:10.1038/jp.2015.183

7. Friedman Peahl A, Heisler M, Essenmacher LK, Dalton VK, Chopra V, Admon LK, Moniz MH. A comparison of international prenatal care guidelines for low-risk women to inform high-value care. Am J Obstet Gynecol. 2020 May;222(5):505-507. doi: 10.1016/j.ajog.2020.01.021. Epub 2020 Jan 18. PMID: 31962108.

8. Miller CA. Maternal and infant care: comparisons between Western Europe and the United States. Int J Health Serv. 1993;23(4):655-64. doi: 10.2190/RR4G-NTB1-L229-FVHG. PMID: 8276527.

9. Gadson A, Akpovi E, Mehta PK. Exploring the social determinants of racial/ethnic disparities in prenatal care utilization and maternal outcome. Semin Perinatol. 2017 Aug;41(5):308-317. doi: 10.1053/j.semperi.2017.04.008. Epub 2017 Jul 29. PMID: 28625554.

10. Kozhimannil KB, Hung P, Prasad S, Casey M, Moscovice I. Rural-urban differences in obstetric care, 2002-2010, and implications for the future. Med Care. 2014;52(1):4-9. doi:10.1097/MLR.0000000000000016

11. https://www.scientificamerican.com/article/maternal-health-care-is-disappearing-in-rural-america/

12. https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/rural-health/09032019-Maternal-Health-Care-in-Rural-Communities.pdf

13. Peterson JA, Albright BB, Moss HA, Bianco A. Catastrophic Health Expenditures With Pregnancy and Delivery in the United States. Obstet Gynecol. 2022 Mar 10. doi: 10.1097/AOG.0000000000004704. Epub ahead of print. PMID: 35271537.

14. https://www.statista.com/statistics/1125599/femtech-market-size-worldwide/

15. https://www.coyote.ventures/_files/ugd/e768ef_ea188df766ed445db2c3f02b47014c60.pdf

16. Pitchbook data

17. https://www.mobihealthnews.com/news/femtech-startups-nearly-double-funding-dollars-last-year-still-make-small-percent-market

18. https://news.crunchbase.com/startups/femtech-vc-investment-startups-womens-health/