She spent a decade trying to build better women’s health care—now her startup is on the brink of failure

Evofem Biosciences CEO Saundra Pelletier is one of the most dynamic, and complicated, entrepreneurs I’ve ever profiled. Over the past two months, she’s also been one of the most willing to discuss her company’s worsening fortunes in real-time, as Evofem slips to the brink of failure.

Starting in 2013, Pelletier spent ten years gritting her small pharma company through a soap opera’s worth of business problems: expensive regulatory limbo; product setbacks; even personal tragedies, including plane crashes and cancer diagnoses. “I’ve never met a person in my life with as much energy as this woman. Ever,” says Russell Barrans, Evofem’s former chief commercial officer.

But today, Pelletier’s ability to overcome seemingly any obstacle is being sorely tested. Evofem’s shares have been delisted from the Nasdaq, and its sales aren’t growing fast enough to overcome its losses (or its debt load). Last month, the San Diego company parted ways with most of Pelletier’s remaining staff, including members of her C-Suite: her CFO resigned, her chief commercial officer was laid off, and her 35 remaining employees took salary cuts of 20%. (Pelletier’s own salary was slashed 40%, to $520,000.) 

“We are on life support,” she says. “There’s nothing I would not do for this company to succeed.”

There are many reasons for Evofem’s current predicament, including some of Pelletier’s own making, as I report in a new profile and investigation for Fortune. But the biggest financial challenges facing Evofem—and all the entrepreneurs and executives trying to innovate in its crucial market—involve our broken health care system.

It’s part of a much bigger story about how reluctant big drugmakers and investors are to spend money on the serious business of women’s health. Women make up 51% of the population and are responsible for 80% of U.S. health care purchasing decisions. Yet Big Pharma spends only 1%—not a typo—of all R&D investment on female-specific conditions other than cancer, according to McKinsey. Things aren’t much better in the VC-backed world: “Femtech” still accounts for only 5% of digital health investment in the United States, according to venture fund Rock Health.  

“Large companies aren’t interested in women’s health—and small companies have a hard time commercializing,” Stifel analyst Annabel Samimy says.

Evofem, which makes a prescription contraceptive gel called Phexxi, tried to innovate in a particularly fraught corner of the women’s health care market. Millions of women want better types of contraception, and the post-Roe v. Wade era has made access to birth control more important than ever. And the Affordable Care Act specifically requires insurance companies to fully cover women’s contraception, seemingly creating a lucrative market for drugmakers developing new products.

But in practice, insurers are widely refusing to cover these new products, my investigation found—making it financially impossible for small contraceptive makers to survive.

“If the plans had followed the rules, we would not be worrying about money,” Pelletier says.

The Biden Administration says it is “actively investigating” reports of insurer noncompliance (while the insurers generally say they are working to comply with the law). Any government action would help the 73 million U.S. women of reproductive age, for whom access to reproductive health care is more important than ever. But it may not come quickly enough to save Evofem–or to encourage other companies to innovate in this crucial, if widely overlooked, market.

I hope you’ll read the full story, which follows Pelletier’s tireless efforts to save her company—while diving into the systemic problems facing Evofem, all of its competitors, and the millions of U.S. women who are their prospective customers.

Maria Aspan
maria.aspan@fortune.com
@mariaaspan

Jackson Fordyce curated the deals section of today’s newsletter.

VENTURE DEALS

- Kite, a New York-based commerce scaling company, raised $200 million in funding from Blackstone and Juxtapose. 

- VintaBio, a Philadelphia-based life sciences company for cell and gene therapy development, raised $64 million in funding led by Decheng Capital.

- CTRL Therapeutics, a Chicago-based cell therapy platform development company for treating solid tumors, raised $10 million in seed funding. General Catalyst led the round and was joined by Intermountain Health, FACIT, and others.

- REPOWR, a Birmingham, Ala.-based logistics marketplace for B2B asset sharing, raised $8 million in Series A funding led by UP.Partners. 

- Assis, a São Paulo-based virtual assistant for freelancers, raised $5 million in funding. Costanoa Ventures led the round and was joined by MAYA, Canaan, Latitud, Norte, FJ Labs, 1616, BFF, and other angels.

- Fire, a Miami-based crypto fraud prevention tool, raised $3.5 million in funding led by Atomic. 

-Portrait Analytics, a Boston-based generative A.I. research assistant platform for investment analysts, raised $3 million in pre-seed funding led by .406 Ventures. 

PRIVATE EQUITY

- MSPB, backed by Ascend Partners, acquired Palm Beach Digestive Associates, a Delray Beach, Fla.-based gastrointestinal health facility. Financial terms were not disclosed.

- Transom Capital Group acquired theBose Professionaldivision of Bose Corporation, a Framingham, Mass.-based audio systems company. Financial terms were not disclosed. 

- Vander-Bend Manufacturing, an Aterian Investment Partners portfolio company, acquired Omni Components Corporation, a Hudson, N.H.-based medical products manufacturer for surgeries. Financial terms were not disclosed.

IPOS 

- ​​TypTapInsuranceGroup, a Tampa-based homeowners insurance provider, withdrew its plans for an initial public offering.  

FUNDS + FUNDS OF FUNDS

- Eclipse, a Palo Alto-based venture capital firm, raised $1.23 billion across two funds. The $720 million fund will focus on pre-seed, seed, and early-stage investments. The $510 million fund will focus on portfolio companies and Series B and C investments.

Correction, Apr. 11, 2023: A previous version of this newsletter misspelled Transom Capital Group and the location of Bose Corporation’s headquarters.