Last year there were 3.59 million births in the United States according to the National Center for Health Statistics, which was markedly down from 3.66 million in 2022, largely due to fewer births by younger women and lower fertility rates. Overall, just over 10% of births were deemed preterm, although there was significant disparity by race and who had access to quality care. Tragically, the U.S. also has the greatest – by far – maternal mortality rates of other industrialized nations at 23.8 deaths per 100k births. And it is getting worse: it was 17.4 just in 2018. Black and Brown women in the U.S. face three times the mortality risk than the broader population.
Source: Centers for Disease Control and Prevention
It is for these reasons that Flare Capital initially seeded Cayaba Care a few years ago and continues to support the company today, particularly with a great new CEO who recently joined the company alongside a terrific Executive Chair, as well as committed and passionate executive and care teams. Cayaba Care wraps around the pregnant mother a comprehensive multi-disciplinary care team to provide a full range of maternity support and educational services in the home and virtually. At the center of the care model is a Maternity Navigator, once again underscoring that great care is ultimately facilitated by human-to-human interactions, augmented by an app that facilitates nearly three dozen virtual interactions over the course of the pregnancy.
In addition to the greater than 10% incidence of preterm births, it is estimated that upwards of 20% of pregnant mothers present with a degree of mental health issues. The incidence of post-traumatic stress disorder (PTSD) among perinatal women is estimated to be 3% – 4%, and significantly higher for Black and Brown women. In one study based on data from Optum’s Clinformatics Data Mart Database, perinatal PTSD increased nearly 400% since 2008. As it is, nearly half of all women describe childbirth as “traumatic.” Other risk factors that contribute to perinatal PTSD include pre-eclampsia (high blood pressure due to pregnancy; 2% – 6% of pregnancies), comorbid psychiatric conditions, social risk factors, and general poor health (obesity, etc). Analysts estimate that emergency room visits can be as much as $8k more expensive for Medicaid mothers with depression symptoms than for those without such issues.
Incidence of Preterm Births
Source: National Center for Health Statistics
A particularly vulnerable population includes women struggling with severe mental illnesses (SMI) which includes bipolar disorder, schizophrenia, schizoaffective disorder, and major depression. While many of these patients are treated in outpatient mental health clinics, if they are treated at all, they are often completely ill-equipped to navigate maternity. These women have much greater incidence of unintended pregnancies and with complicated, and very expensive, births. An inability to be an effective parent often leads to loss of custody, further burdening local social services infrastructure. A recent study of this group conducted by the Los Angeles County Department of Mental Health highlighted how critical it is that issues around pregnancy and parenting need to be deeply embedded into overall mental health services.
The criticality of the unmet needs of the SMI population lead to the creation of Author Health by Humana, General Atlantic, and Flare Capital in March 2022 with a $115 million Series A financing.
While early still, the initial data from Cayaba Care are very encouraging. Across all relevant benchmarks monitored by the March of Dimes (preterm, C-section rates, NICU weight, etc), Cayaba Care is exceeding 80% of those thresholds. The estimated cost savings (claims reduction) per birth appear to be trending to at least 16% – 20% reduction, and importantly, with enhanced quality of care. Specifically, there is a greater than 25% reduction in ED visits for mothers managed by Cayaba Care. Such an approach also identifies the mothers early who are at the greatest risk and can fundamentally redirect the trajectory of those pregnancies.
There is a significant data opportunity being addressed by another Flare Capital portfolio company, HealthVerity, a leading healthcare data management platform. One of its interesting products is called “MOM,” which is a HIPAA-compliant data masterset of two million paired mothers and babies that replaces the need for expensive registries to follow mother/baby pairs.
Although it does not change the overall severity and urgency of these issues, there is one small word of caution concerning the data. The American Journal of Obstetrics & Gynecology recently cited a death certificate modification in 2003 which simply noted whether someone was pregnant or not at the time of death, perhaps attributing and overstating a death to being due to maternal health issues. Researchers concluded that deaths solely due to obstetric issues decreased slightly since 2003, and occasionally included certain cancers in maternal death figures.
These risks were particularly prevalent in teenage pregnancies. A recent Canadian study of 2.2 million pregnant teenagers concluded that teenagers who carried pregnancies to term were more than twice as likely to suffer pre-mature death. Even those young women who aborted the pregnancy were still 40% more likely to suffer a pre-mature death when compared to teenage girls who were never pregnant. A 2017 study in Finland attributed greater pre-mature death rates for pregnant teens to suicide, alcohol-related issues, and circulatory disease.
While the number of births have steadily declined over the past 20 years, the general fertility rate has dropped even more so and is now 54.4 births per 1k women while the total fertility rate is 1.62k per 1k women. To maintain the current U.S. population, the sustainable fertility rate would need to be 2.1k per 1k women.
Source: National Center for Health Statistics
It appears that the U.S. medical community is quick to perform cesarean section (C-section) procedures with 32.4% of all births by C-section, which is the greatest percentage since 2013. Black women experienced C-section in 37% of all births in 2023, while white women were at 31%, suggesting a level of disparity. C-section rates were particularly elevated in the South. The World Health Organization suggests that the ideal amount should be 10% – 15% overall. While still debatable, it is unclear that for many C-sections that the procedure is medically necessary, and undoubtedly these procedures introduce elevated immediate and longer-term risks and complications given how invasive the procedure is.
Percent of Deliveries by Cesarean Section
Source: Centers for Disease Control and Prevention, Axios
The dearth of adequate solutions purpose-built to address issues uniquely confronting women’s health have not been lost on venture capital investors. Over the last decade across all types of investment an estimated $23.8 billion has been invested in 1,646 companies in the “femtech” sector, according to Pitchbook. There was a significant influx of capital in 2021 which has moderated quite materially since then. In 2023, the median round size and post-money valuation were $1.0 million and $11.1 million, respectively, suggesting that the sector is populated with many small (i.e., sub-scale) companies. Expect a period of rapid consolidation as many of those companies will either run out of cash and/or need to provide a more comprehensive end-to-end solution.
Amount Invested in “Femtech”
Source: Pitchbook
Number of Investments in “Femtech”
Source: Pitchbook
Oncology is another field garnering attention. Sadly, Black women have the lowest and shortest cancer survival rates among all racial groups. The American Cancer Society (ACS) recently announced that 100k Black women are to be enrolled in the largest cancer study for this vulnerable group. Across all races, ACS data shows that the death rate is 146 people per 100k and nearly 169 per 100k Black Americans.
One glimmer of a silver lining has been the employment situation for women. There has never been a time that more women have been employed. Economists attribute this to more flexible workforce rules and hybrid office arrangements. To the extent health benefits are provided by employers, it is hoped that services offered by companies like Cayaba Care will be more prevalent and accessible to women who so desperately need such support. A study by Boston Consulting Group and Moms First concluded that for every dollar invested in childcare benefits, employers realized between $0.90 – $4.25 of net gain due to reduction in absenteeism and less attrition.
Source: Bureau of Labor Statistics, Axios
Take two (baby) aspirin – and hopefully you will not have to call the doctor in the morning. The U.S. Preventive Services Task Force, American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine all support daily doses of aspirin for pregnant women to effectively reduce risk of pre-eclampsia (15% reduction), premature births (20% reduction), and intrauterine growth restriction (18% reduction). Greater education and access to appropriate care will undoubtedly have dramatic benefits, especially for those of us on the fringes of the healthcare system.
On the Flying Bridge 