Assembly Select Committee on Latina Inequities

Good morning, everyone. The select committee on Latina inequities hearing will now come to order. Before we begin, a few housekeeping notes. During the hearing, we ask that there please be no disruptions from the audience. Public comment will be taken once the presenters have concluded and must relate to the subject of today's hearing.

After, your testimony, you may exit the room or return to your seat. Please be aware that violations of these rules may subject you to removal from the hearing room. I also ask that our presenters be mindful of time so that every voice on today's agenda has room to be heard, and I'll give a gentle signal when time is running short. Actually, generally, it may give you that gentle signal. Thank you all so much for being here.

I wanna open today not as a legislator reading findings into the record, but as a woman who has spent my life inside of these questions, first as a daughter and sister in a Latino family and later as a social worker trained to ask why disparities persist. Aye, myself, have sat in waiting rooms. I've watched women in my own community be talked over, rushed, or not believed.

And I've also watched what happens when a woman is met by a provider, a promotora, a doula, or a community health worker who actually sees her. The outcomes are not the same.

That gap between being seen and being treated is what this hearing is about this morning. Disparities are rarely the product of a single failure. They're an accumulation of many small system decisions compounding over generations. Who or what gets funded, who gets believed, or who gets studied, whose pain is documented, and whose is not. Today, we're gonna look at those accumulations directly and learn what it would take structurally and legislatively to dismantle it.

This hearing is intentionally built around the state's data and the lived experience of communities most affected by it because policies that not grounded in both do not provide the meaningful change that it is intended to. Our goal today is threefold. It's to examine the state of reproductive and maternal health disparities affecting Latina, black, and indigenous women in California, to evaluate honestly whether current state and community interventions are working, and to identify concrete legislative and policy actions this body can take to close those gaps.

I wanna be explicit about one thing. Women of color is not one experience. A Latina immigrant navigating language access, a black mother navigating implicit bias in a delivery

room, and an indigenous woman navigating a delivery room, and an indigenous woman navigating a geographic and jurisdictional maze of care are distinct barriers that intersect. We've built today's agenda to honor those distinctions, not flatten them. I wanna thank every presenter who is here today for trusting this committee with both your data and your stories. With that, I wanna just give a quick overview of today's agenda.

Today's hearing is organized into two parts, recognizing that women have the right to choose whether they want to become a mother, and that it's imperative that they are supported with either choice.

The first part of the hearing will examine the roots of reproductive health disparities. Our second part will narrow our focus specifically to maternal health. Following each part, committee members will have the opportunity to ask questions. We will close with public comment and brief remarks. So to get started and to invite our first presenters up, and to ground today's oh, pardon me.

I wanna turn it to other members if you have any remarks to open today. Go ahead.

Thank you. I'm I wanna appreciate our Chair here on this committee and also all of those individuals that will present to us. But especially the theme, I think, when you look at the select committee, many of us can identify with these themes throughout our life. And not only does health intersect, but when we look at our big structures like education, we can see these same themes that appear, whether it's families.

I was a elementary school teacher for almost thirty years, and it was the same type of themes, access, interpreters, making sure that families understood what was available to them.

And too often, we make steps, and yet we still see some of the same results. Just yesterday, we sat in a select committee hearing on native American in returning their, not only their artifacts from our UCs and c CSUs, and we've heard it over and over of recommendations and then the nonurgency to follow-up. So we have to continue to march. We have to continue to advocate, and then we have to have enforcement.

Personally, speaking about maternal health, my daughter had a late pregnancy loss, close to her thirtieth week.

And one of the things we saw with that, was that although she delivered, then the systems that follow, she was getting congratulation notes from the hospital even though the baby did not survive. All of these systems that are in place are not looking at that individual woman who really needs care. So I'm pleased to be here. I wanna thank you for this.

Again, thank you all for being here and pointing out all of the systems that really don't come back to one person or one policy, but are rooted in a much longer history of groups and people not being heard. And that's really the theme of today. So thank you for your remarks.

It's my honor to introduce our first panel, Clarissa Ramirez, who will be joining us virtually of California Latinas for Reproductive Justice, Sofia Pedroza, a Planned Parenthood affiliate to California, and Kim Robinson, a black woman for wellness. If you could please join us up here.

Clarissa, would you like to start us off?

Sure. I can hello. I'm so happy to be here with y'all today. Please let me know if you can't hear me or if I'm going over in time. But as was shared, my name is Clarissa Ramirez. I am the policy manager here with CLRJ. My pronouns are she, her, and ella.

Next slide, please. Thank you. First off, I wanna just give a little background about CLRJ. CLRJ is a statewide, policy advocacy organization that centers the experiences of black indigenous and other people of color within the Latina diaspora, to uphold our dignity, our bodies, our sexuality, our diverse families, and our communities. Since 2005, CLRJ has been the only Latina led reproductive justice organization in California.

And for two decades, we have built power through community organizing, policy advocacy, culture shift, and community informed research. Our anti eugenics lineage, twenty years documenting coercive reproductive practices, sterilization abuses, and the history shaping Latina and Latine health care today position us to lead, not cosign any post ops analysis from a Latine standpoint.

And just a quick note, we at CLJ use, opt to use Latine instead of Latinx, Latino, or Latina, in order to reflect the most gender inclusive and phonetically accessible language used to describe our community. Next slide, please. So first, just a quick background on RJ.

It's a a term that was coined by black women in 1994, sister song. RJ looks at Reproductive Health, which is those services, and reproductive rights, which are the laws through a human rights and social justice framework. RJ has four core tenants, the right to bodily autonomy, which is the ability to freely make decisions about one's own body life, free of coercion. However, barriers to exercising that right exist, and those barriers can look like anything from stigma to Transphobia, socioeconomic status, coercion.

So anything any of those barriers affect somebody being able to access their right to public autonomy.

The next two tenants of RJ include the right to have a child and the right to not to have a child. That includes abortion and also conversations around deservedness and who gets to be a parent. And then fourth is the right to parent the children that we do have in safe and sustainable communities regardless of who we are, who we love, where we're from, and what languages that we speak. Next slide, please. I wanna go into reproductive oppression really quickly.

Reproductive oppression is the control and exploitation of people's bodies or sexuality or labor and our reproduction. It shows up a lot of different ways throughout our history, mainly in, you know, control of black women's fertility during slavery, shackling of incarcerated people during birth, the denial of gender affirming care or forced procedures on intersex individuals, and nonconsensual drug testing of pregnant people. Reproductive oppression is a result of white supremacy and eugenics.

And if it says that, those of us that do not fit into their ideals are not worthy of reproductive freedom. Next slide, please.

So for sterilizations, beginning in nineteen o nine and continuing for about seventy years, California led the country in the number of sterilization procedures performed on men and women, often without their full knowledge and consent. It's estimated that of the sixty thousand people were that were sterilized as a result of national eugenics efforts, California is responsible for 20,000.

And while California eugenics programs and policies were driven by anti Asian and anti Mexican prejudice and hate, it is really seen as a really common sense practice that was meant to protect the state from in quote, unquote, increased crime, poverty, and racial degeneracy, whatever that looked like or whatever they thought that meant at that time.

And in the state of California overall, Latino men were 23% more likely to be sterilized in while they were wards of the state, And Latinas were 59% more likely to be sterilized than their non white or than their non Latina counterparts. Sonoma sorry.

Next slide, please. Sonoma State Hospital is actually responsible for the largest amount of sterilizations that were performed at the hands of the state with roughly fifty four hundred. And of that fifty four hundred, almost three thousand were performed on Latine patients alone, and the average age of sterilization was 17 years old. The state of California was sterilizing children. This practice stripped individuals of their humanity and was legal based on diagnoses with no real scientific or diagnostic backing and certainly none that would fly today.

In fact, officials at the time described Mexican Americans as inherently less intelligent. We were described as immoral, hyperfertile, and criminally inclined. Next slide, please. In LA County specifically, LA, hundreds if not thousands of Mexican women were coerced into sterilization, often while they were giving birth at LAC USC Medical Center in the nineteen sixties and seventies. A quick note on LAC USC, their name has changed so many times that you'll see them described as LAC USC, LAC GH, and I think most recently it's LAGMC.

In literature, you'll see any of those three. It's the same hospital. And so in 2024, there was a feasibility study that was actually performed to see, look into the patients to see how feasible it would be to to compensate them the same way that patients who were sterilized by the state. And what they found were some main core points. Most first was most impacted victims were Hispanic, Latino, immigrant women.

Next, the sterilization incident typically took place while giving birth with many women being told that they would not be helped unless they agreed to having their, quote, unquote, tubes tied. And even around that point, there was no clarity on on really what having your tubes tied meant. Some patients thought that they could have it reversed and it was easy to be reversed.

The next point was that women were either coerced into signing a consent form or were completely unaware what they signed and that this consent form that they signed led to a procedure that took place. Family members were not allowed to accompany women into the birthing room, so they were in the throes of labor being asked repeatedly to sign documentation, to sterilize them or to sign documentation with no translation provided.

And when many learned that they were sterilized, these women expressed feelings of shame and fear of being judged. It was seen as a personal failing that somebody else did this to them. Next slide, please. LACGH, again, I just referred to it as a different name than I did in the last night. Apologies.

But that hospital operated so insidiously that many women did not learn that they were sterilized until years later when a young Chicana lawyer brought this case to light. She's actually in the top right corner. Antonio Hernandez, I believe. Madrigalbe Quilligan is one of several landmark cases in reproductive justice history. 10 Mexican women stood up to the hospitals, the state of California, and to the Federal Government to denounce what happened to them and to demand justice.

And, unfortunately, while they didn't win their case, the hospitals do now provide translation for consent forms, and a wait period is required for someone to sign consent to being sterilized under using Medicaid dollars. Next slide, please. About eleven years ago, we at CLRJ were asked to be a community partner on the documentary, Nomas Bebes, which gives a detailed look into the lives of those 10 women who sued doctor EJ Quilligan.

It also looks into the case itself and the culture of the time that allowed this to happen. Starting in 2019 with AB 1764, CLRJ joined a strong coalition of researchers, policy advocates, lawyers, and survivors who sought to create compensation for those forcibly or involuntarily sterilized by the state.

And while it took an additional two iterations iterations of and a budget ask, AB 107 was signed into law in October 2021, and the forced involuntary sterilization compensation program was established. This program was meant to provide reparations to survivors of forced sterilization in state institutions and prisons who were overwhelmingly people of color, disabled, Latinx, and people living in poverty. Next slide, please. So in California, the racist, xenophobic legacy of eugenics persists.

It's not just through the efforts to deny Latina women our right to parent, but also to deny their right to not parent.

This agenda of reproductive coercion assumes many forms. Forced sterilizations in ICE detention centers is one. Another is the state and federal laws that push abortion care contraceptive, contraception and other essential sexual reproductive health care out of reach for people who are struggling financially.

And in recent years, we've all we've also witnessed the Trump administration block, detain undocumented minors access to abortion care as an extension of this aggressive agenda on Xenophobia, agenda of Xenophobia and misogyny, and denying black and brown women autonomy over their lives and their futures. Next slide.

Attacks on reproach health care that disproportionately harm Latina and immigrant communities carry long term and even deadly impacts. In California, Latinas have reported experiencing discrimination during childbirth and feeling unsupported in their reproductive decision making. Language barriers, immigration concerns, lack of representation among health providers, and a lack of insurance coverage all contribute to the deadly outcomes and all our product of white supremacy and the legacy of eugenics. And then next slide, please.

On the topic of cultural taboos, we invite all legislators to take part in a culture shift with us.

Conversations about cultural taboos really perpetuate harmful stereotypes about our community Through our speaking story initiative, we have learned that by sharing our stories and supporting others and sharing their stories, we can work toward a cultural shift to bring new meaning and reproductive justice, to document our experiences and those of our communities, and to fight for Latinas and Latinas' rights to self determination for ourselves and our families. There is so much diversity in Latinidad. We are not a monolith. We don't all hold the same beliefs.

And often what was thought of as taboo was really just conversations that there was so much stigma and shame around, not necessarily taboo.

Folks were more worried about being judged themselves than worrying about judging others. And we at CLJ would really encourage generational learning through facts and storytelling rather than perpetuating stereotypes about anyone in our community. And we would encourage all of y'all to take a look at our our archive on on SoundCloud if you'll ever get a chance. Next slide, please. Thank you.

That was Thank

you so much.

Appreciate it.

Thank you for your presentation. And, each of our panelists will be here for questions at the end. But if anyone has a question now, I wanted to pass open it up just in case. Thank you so much for grounding us in that history.

Yes. I just wanted to thank the presenter today. I'm sorry I have to leave, but this is information that's been hidden hidden from so many of us for so many years. Many have experienced these things, and it's never been talked about. I think one of the things being a Latina that our families would sit around the table, and we wouldn't talk about these things at all.

And you look across the room, and the first thing my family would do when we had a difficult conversation about women's health is they say put the zipper on it. And we were held quiet for years. So thank you very much for presentation.

And thank you for pointing that out. I think one of the things that stands out a lot to me is this idea sometimes often that our Latino community is a monolith. And there are these assumptions about, you know, our culture and sometimes how our faith is connected to our culture and automatically these assumptions about how we feel about things like abortion, for example. But the conversation is so much deeper than that one.

It's about, you know, not having the right to decide not to be a parent, but also in our own history, there was a decision made for so many women in our community that they wouldn't be able to become mothers even if they wish to and why it's so important to look at how the government should never interfere at all with either of those decisions.

So thank you again for your presentation, and please stay around in case another question comes up. We'd be grateful for that.

Thank you. Appreciate it.

And then up next, Sofia, would you like to present?

Thank you. Yes. Thank you. I wanna begin by thanking the select committee for hosting this informational hearing for continued leadership on policies that address inequities affecting black and indigenous women of color, including Latinas, and I wanna thank my my co panelists for their valuable contributions today. Today across the state, Planned Parenthood affiliates are working to improve access to sexual and reproductive care in their local communities.

I am here as legal counsel for Planned Parenthood of California and the 100 health centers that are run throughout the state, providing 1,300,000 patient visits annually for individuals in all 58 counties. Now these health centers span the state, reaching from Eureka to

El Centro near The US Mexico border, almost 900 miles away. And there are also health centers even in the most rural parts of our state. Think Antelope Valley, Victorville, Ukiah, Redding. In addition, our affiliates also provided almost 100,000 telehealth visits in 2024, making virtual care accessible to patients who need it. Now our affiliates, first and foremost, work to build trust in our communities knowing these histories by providing quality and comprehensive care.

In California, this looks like 25,000 patients receiving care through our health centers every week, with three out of four identifying as people of color, nine out of 10 having incomes below 200% of the federal poverty line, and four out of five being under the 35. Now more than half of our patients identify as Latino or Latinx. Now affiliates also operate several health centers with extended hours and weekend hours to accommodate patients who have inflexible work schedules, who have child care needs, or other unique scheduling challenges.

Access to care with a trusted provider is crucial for these patients who are more likely to have lower incomes, poorer health outcomes, and who experience discrimination and injustice within the health care system. So for our affiliates, it's important to work to address inequities by being a one stop shop for care, for education, for warm handoffs, which are all known to improve health outcomes.

This is especially true in areas where patients face compounded barriers. A meaningful relationship with a local community can actually increase the quality of care. For example, some affiliates have Promotoras program. Planned Parenthood Los Angeles, just to give one example, has a program that's been around since 1991, and it's trained over 1,200 Promotoras to be out in our communities providing education.

The program is a trusted messenger in many LA communities because the promotoras live the same experiences in the same area as the community members that they dialogue with, and they quite literally care about the well-being of their neighbors.

They talk about sexual and reproductive health, mental health, substance abuse issues, and so much more. They're a bridge to social services across the board, such as housing support, legal services. Just last year, the program reached more than 36,000 people through education, community events, and even in consulates, representing Mexico and Guatemala on tables tabling on-site where people could access health care information while waiting for their appointments. Affiliates work to provide culturally responsive care specifically to meet the needs of California's diverse populations.

All of our health centers offer language access, for California's many communities, including multilingual staff, that are catered to the specific local communities in the area, as well as video or telephone translation access in 200 languages plus.

Just to give one example of what this means for patients when put all together, a patient came in to our Central Coast affiliate for a pregnancy test. She did not speak English or Spanish, but she spoke an indigenous language, because she was from a local indigenous immigrant community. And so the staff interpreter working in that health center was able to work with her from start to finish in her language fluently.

And during the visit, the patient reported that she had been sexually assaulted, that she was pregnant as a result, and she sought an abortion. She was extremely scared, and she was not sure if she would be able to come back for another visit.

Staff were able to do rapid testing to determine whether she had acquired an STI. They provided the abortion she sought, and they inserted an IUD. The patient told her clinicians that they helped her more than anybody else, particularly because all services were provided in one visit. In another example, our Marmonte affiliate assisted a patient who was working as an agricultural worker, and they were uninsured.

So they helped him to enroll in the family pack program and performed a preventative care visit where the clinician identified some concerning findings.

However, being the one stop shop, Marmonte was able to order the imaging and diagnostic testing necessary that resulted in a cancer diagnosis. Marmonte went a step further and facilitated a referral to an oncology provider and supported that patient in enrolling in additional public coverage programs to cover the cost of that forthcoming treatment.

So taking a patient centered, community centered approach means ensuring that patients can access the care they need as efficiently as possible, including considering what barriers they might face before they're even in the health center. And so providers must be prepared to fit to serve both the patient who only foresees one possible visit and the patient who suddenly needs longer term, more complex care. Beyond the confines of one single appointment, our affiliates also provide education services as key community partners around the state.

All seven affiliates offer education and counseling on sexual and reproductive health, reaching nearly 100,000 Californians every year. For example, Planned Parenthood Los Angeles provides education to parents and students through 26 well-being centers, which are school based partnerships with the California Department of Public Health. Through these centers, they are able to educate students while providing the same education to parents to open lines of communication with families about sexual health, mental health, and substance abuse issues.

And these issues can be very sensitive in our communities, as folks have referenced. So opening channels of communication gives the opportunity and the tools to start these conversations within our families where it's already so difficult.

The important work of building trust with patients in our communities is bolstered by years, years of education focused work with community members and partner orgs. Across the state, folks can connect with promotoras of different affiliates, utilize the Black Health Initiative in LA, which works directly with Cedars Sinai to coordinate prenatal and advanced OBGYN care, where they can receive sex ed, as I mentioned, at a consulate. The innovation of the affiliates in this space might surprise you.

For example, Planned Parenthood Southwest runs a free program called sex ed to go, one of our most successful education programs. It's a series of short modules covering topics like anatomy, consent, relationship skills, black maternal health, how to access health care, and it's in English and Spanish.

The coursework has content, again, for parents and educators who can learn how to support their families or their young students. Another example, Planned Parenthood Mar Monte has a sex education video game that's actually designed and inclusive of Spanish speaking communities and tailored to be played by a teen and a supportive adult. And so it creates a safe and inclusive learning environment for both on how to navigate this educational material.

Again, this work is not one size fits all, but it's based on community relationships, our knowledge of those who live around, those who do work in the community, and the affiliates have spent years cultivating this work. However, that rapport has taken years to build and is currently under threat.

Federal threats to sexual and reproductive health care and education continue, and the consequences are real and happening now. In just one example of the many federal attacks of impacting this work, recently, the Federal Government issued harmful changes to requirements to receive funds through the teen pregnancy prevention program, also called TPP.

These changes seek to align sex ed program implementation with several executive orders, which would effectively result in sex ed that's no longer age appropriate, no longer medically accurate, It would not be nonjudgmental, and it would not be inclusive of all sexual orientations and gender identities or expressions. As a result, multiple affiliates have had to make tough decisions to decline future funding, and this effectively amounts to a cut.

As a result of this and multiple cuts, one affiliate has had to cut their education staff from 28 to six.

Another had to field questions from parents about why their award winning education program for individuals with developmental delays was canceled, And so many of these programs were direct impacts for communities. Our affiliates have spent years cultivating relationships with communities that might even surprise you, from farm workers to sex workers to students to immigrants to students with disabilities and so much more.

And so in the face of these relentless federal attacks on access to sexual and reproductive health care and education, it's as important as ever to continue fighting for the services and the community supports that folks rely on because our health programming is tailored and focused on reaching our local communities and very, very consciously includes outreach for black and indigenous women of color, including Latinas, including anyone who lives around the health centers.

It it is such a curated effort, and so our continued work to advocate for for health care access and education is is essential today. Thank you.

Thank you. Kim, wanna bring us home on this panel?

I sure will. I thought I saw my slides earlier, but maybe they'll come up. So good morning, and thank you for the opportunity to be here today. My name is Kim Robinson, and I serve as the community liaison and policy analyst with Black Women for Wellness and Black

Women for Wellness Action Project. And we are based out of Los Angeles and also in Northern California in Stockton, and I work in our Stockton location. And our mission is to support and help the health and well-being of black women and girls, and we do that through policies and programs. And so every day, I work alongside black mothers, families, health care providers, community organizations, and policymakers to improve reproductive health care across California.

Today, I'd like to share why community led solutions are essential to advancing black maternal health, how Black Women for Wellness is helping lead that work, and what legislative staff can do to support lasting systems change.

This conversation isn't just about improving health care. It's about ensuring every black mother has the opportunity to experience a healthy pregnancy, a safe birth, and respectful care before, during, and after childbirth. Next slide, please. Black women continue to experience some of the worst maternal health outcomes in California and across the nation. Despite California having one of the lowest maternal mortality rates in the country, black women remain several times more likely to die from pregnancy related causes than white women.

It's actually three to four times more likely. We know these disparities are not caused by race. They're caused by structural racism, unequal access to quality care, chronic stress, environmental exposures, economic injustices, and policies that have historically excluded black communities from resources and decision making. Data shows that these outcomes are preventable. Health equity begins long before someone enters a hospital.

It starts with stable housing, clean neighborhood, economic opportunity, reproductive freedom, and health care systems that value black voices. Next slide, please. When we talk about black maternal health today, we have to understand the history that shaped it. The disparities we see today are not a result of individual choices. They are a result of generations of policies and systems that have affected how black communities experience health care.

From chattel slavery and the exploitation of enslaved black women in the development of gynecology to Jim Crow segregation, forced sterilizations, and unequal access to quality care, history has influenced both health outcomes and trust in the health care system. While the civil rights movement and programs like Medicaid expanded access to care, access alone does not eliminate disparities in quality, respectful out and or outcomes. Today, even in California, barriers such as providers shortages, transportation, insurance, and culturally responsive care continues to affect black maternal health.

Understanding this history is essential because it remain it reminds us that today's inequities are rooted in policy, and policy can also be a part of the solution. As legislative staff, you have the opportunity to support policies that build trust, strengthen community based care, and advance reproductive justice so every black mother and family has the opportunity to strive.

History shapes today's outcomes. If policies contributed to these inequities, policies can also help dismantle them. Lasting change happens when legislation is informed by history guided by our community voices and grounded in reproductive justice. Next slide, please. The data tells an important story, but behind every statistics is a family.

It's a mother. It's a birthing person, a child, and a community. California has made important progress in improving maternal and infant health, and we should recognize that. But overall, pregnancy related severe maternal morbidity, and preterm birth rates have declined. But when we look beyond the statewide averages, we see that black women and babies are still experiencing disproportionately worse outcomes.

Black women continue to have the highest rates of pregnancy related mortality and severe maternal morbidity, and black infants are more likely to be born preterm than other racial or ethnic groups. These disparities is not about race. They're about the impact of structural racism, unequal access to quality health care, chronic stress, and long standing inequities in our health care and social systems. And so data must be paired with community voices.

Statistics tell us what is happening, but black women tell us why it's happening and what solutions are needed for California to a tree to achieve true maternal health equity.

We must pair data with investments in organizations, culturally responsive care, community health workers, doulas, and policies that address the root causes of these inequities and not just the symptoms. Next slide, please. As someone who serves Northern California, these numbers are more than statistics. They represent families in our own communities. In San Joaquin County, black infants are disproportionately affected from the very beginning of life.

Black babies are more likely to be born preterm, more likely to have low birth weight, and face approximately twice the risk of infant mortality compared to other infants. These disparities persist regardless of income or education. Factors such as chronic stress, unequal access to quality, perinatal and postpartum care, environmental exposures, and structural racism all contribute to these outcomes. These numbers become more than just urgent when we consider what is happening locally.

Between January and April, San Joaquin County had five black infants deaths attributed to sudden infant death syndrome, also known as SIDS.

While each case is unique and SIDS have multiple contributing factors, these losses remind us that black families continue to experience disproportionate risks well beyond childbirth. Next slide, please. So we've talked about data and history. This slide is really about where policy intersects with people's daily lives. Every icon you see here represent a policy decision, housing, transportation, environmental quality, food access, and economic opportunity, all that are all shaped by legislation, and each one influences maternal and infant health.

This is why Black Women for Wellness approaches maternal health through a community solutions lens. We know health care systems cannot solve these challenges alone. Lasting changes happens when community organizations, health care providers, public health agencies, and policymakers work together to address the conditions that families experience every day. So one thing that I want to to ask is who is really doing this work in the community, and how can state policy support them?

When we invest in trusted community organizations, create sustainable funding for community health workers and doulas, strengthen environmental protections, and include community leaders in policy development.

We are not creating new solutions. We're scaling solutions that communities have been leaning for for years. And this is how we move from reacting to inequities to building systems that prevent them. Communities don't just need to be fixed. They need to be trusted, resourced, and included.

Our role is to advocate and remove barriers so community led solutions can thrive. Next slide. So as we discussed, black maternal health is about much more than health care. It's about creating conditions where black women and families can thrive. We advocate for policies that address full spectrum of reproductive justice.

Our priorities include expanding reproductive health access, strengthening the health care workforce, improving perinatal maternal health services, ensuring young people have access to comprehensive sex health education, advancing environmental justice, and protecting communities from policies that criminalize pregnancies. While most of the bills that we work on, they all share the same goal, shifting our focus from responding to poor outcomes to preventing them. This is an opportunity to think across committees and policy areas.

Housing, environmental protections, education, public health, and reproductive health all influence maternal and infant health care. So policy is one of the most powerful health tools.

We when we invest in our community leadership and reproductive justice, we're not only improving birth outcomes, we're also building systems that allow our families to thrive. Next slide. We've already, you've already heard about reproductive justice, so I won't go into the tenets. But what I will say is that when we invest directly into our black community led community organizations, We continue to expand community health workers and doula program.

Our protections for bodily autonomy strengthens perinatal, mental, and maternal health services, and also addresses some of the disproportionate, situations that happens in our community.

And so next slide. So I'd like to leave you with a few questions and some some answers, but this is Black Women for Wellness's 2026 policy priorities. Some of these bills will be coming to an Assembly for near you. So I I encourage you to please look into these bills and support some of the legislation that we are moving forward to strengthen our communities and to provide, access as we invest in building communities that are sustainable. Next slide.

So as legislators as legislative staff, every budget decision, every policy recommendations create opportunities to improve health equity. So I urge you to ask yourself, who is missing from the conversation? Whose voice shaped the policy? Are we investing in prevention or only responding after harm occurs? Does this proposal strengthen bodily autonomy?

Does it build trust? Does it reduce structural barriers? And are community expertise involved in the decision making process? And so next slide. So as I close today, I'd like to leave you with this thought.

Black maternal health is not simply a health care issue. It reflects the policies we choose, the communities we invest in, and whose voice we value. We know that communities already have the knowledge, leadership, and solutions. Our responsibility is to ensure that those solutions are supported through policies, sustained investment, and meaningful partnerships. As legislative staff, you have the opportunity to champion policies that strengthen community base, invest in community led organizations, and expand access.

Together, we can build a California where every mother, every baby, every family has the opportunity to be healthy, safe, and thrive. And so I'll leave you with this. When we center black women, we don't just center outcomes for one community. We build stronger, more equitable systems that benefit everyone. And so thank you for your time, your partnership, and for your commitment to advancing reproductive justice and maternal health care across California.

Thank you, Kim. I really appreciate your sentiments at the end and recognizing just as we just support women, we're supporting children in entire communities. But the data is stark. It's so unacceptable. I think we need to educate people to let them know, right, that that black women are three to four times more likely to pass and having you know, making the choice to have a child should not result in death.

Right. And to your point, there's so many things that go into it, but the fact that these are preventable is such a critical piece that we wanna talk about today. In the next panel, we're gonna dive into data and the health care pieces of that. But I appreciate you bringing the community lens, and I wanted to recognize that you pointed out the data doesn't reflect everything. There are gaps in it.

And I wondered how knowing that trust is such a critical component of solutions, how do we measure that and then make sure that though that piece of the improvements is actually Harabedian? And what could the state even do to support something like that?

Thank you for that question. So the way that we measure it is we host listening sessions throughout the communities and hear from from the communities what is actually happening. We also provide tours to birthing hospitals so that the birthing community can have an opportunity to see the structure of the hospital, meet hospital staff, and have those conversations and be able to ask questions before they enter when they're in labor and some of the things is out of, you know, their hands. So we do that.

And then we also was a cosponsor on one of the pieces of legislation, Assembly bill 2319, which was the implicit bias in cultural competency training that providers are supposed to, have they're supposed to take and also do a retake every two years.

So what the state can do with that and we have been working closely with Assembly with, attorney general Bonta's office in making sure that those, trainings are happening. When we see that our birthing community is, thriving and wanting to go to appointments and, excited to to meet and talk with their providers, that's another way because I oftentimes hear from folks that they don't wanna go to appointments because they see different a different provider every time they go because of the structure of that that facility.

And so they feel like they have to retell their story all over again and what type of continuity of care is that bringing, especially when you're, going through your perinatal journey. The other thing that, I would like to share is that, treating people with respect and dignity, and we shouldn't have to have laws to Bless you. Dictate that and to say that this should happen.

And so looking at a person as that person and, you know, our providers took a oath to to help and support and guide folks through their journey. And so just being being that, I think, would also help our communities as well. Yeah. And having more folks that look like us in those positions of when we go in to see a provider. Yeah.

Thank you to all of you who provided testimony. And, unfortunately, the data, I think, is clear, which is why we're here. And yet I'm really pleased that you're talking about the training. As we know, there are many, many health care providers who most of the women we're talking about are going to see. And it does make a difference if they've had that training, particularly the nurses who are mostly women, not all.

It's a growing body of men who are nurses, but it's from the the moment they walk in and out their experience. It's like us, all of our experiences and what we take away.

They talk to their neighbor, their neighbor talks to but what my question is is related to ICE right now And related to immigration, not just the women that are now incarcerated because of that, but the women that are carrying that with them and and maybe not seeking appointments, missing appointments, trying in many ways maybe to do this on their own. Can you you speak to that, Sofia?

It's been a tumultuous time. I think that this issue continue has even before this administration, ICE has always been a real factor in whether or not folks feel safe to access public services, to access health care. And the the current moment we're in now, we see if we take an intersectional lens, you know, folks are afraid of ICE, of public charge, of, you know, what getting access to health care they need now could mean for their overall future and for their family's overall future.

So I thank you for bringing that up today. With regards to what our health centers are doing, this has been something that, you know, we've thought about well before, you know, 01/20/2025, and it's certainly something that our health centers have doubled down on to try to make patients understand that we will do everything we can to ensure that they can safely access care with dignity, and it's something that we will continue to do.

And that's also part of the work that is so important for us to do outside of the confines of an appointment time to make sure that even before someone sets foot in a plan granted health center, that they know that the staff are gonna do everything they can to allow them to safely access care.

Can I also ask my question is are you seeing a significant drop off or even hearing in the neighborhoods of a woman who's pregnant that just isn't getting any kind of care or that type of scenario?

Yeah. We do. We see it in San Joaquin County. And one of the things that we have done to address that is to increase our community health worker and form a thorough programs to where we can do home visits.

So that way, we have trusted members of the community who's actually reaching out to the birthing community and could go to their home to help them to assist them with some of the needs that they have and also to, go to those appointments with them so they have a trusted person that is, following them through their care.

And then also giving them the tools, and resources that they need to keep themselves safe.

Thank you. I wanna see

Clarissa, did you hear Assemblymember Quirk Silva's question and and just wanna see if you had anything to add?

I did hear the question. We don't generally deal with patients, but we do know that there is a a real fear in the community. Seeking care will see a lot of folks, even just anecdotally within, like, our networks. Folks are delaying care, are expressing, concerns in going to the doctors. And so we really appreciate the efforts of organizations like BWW in meeting, their patients where they're at, ensuring that they're able to receive the care that they can, free of fear, free of detention.

Yeah.

And I think that just comes back to the trust point and how historically that trust has been broken. And while there's been so many efforts to rebuild it, here we are again where people don't feel safe. My last question, and always feel free to cut me off, is around the loss of health care for so many of our community members that has happened and is looming.

How are you all responding to that and preparing, and what can the state do to support knowing that we have so many folks up here that are doing our best to do everything we can, but we wanna hear from you.

That is also a good question that, you know, we try to address every day. And it's not only the loss of health care services. It's also organizations are also losing the resources that they have to try to fill those gaps. We have organizations that have to pivot their programs because funding have been cut, which is leaving our communities also, in a, I hate to say, but desperate situation.

And so funding opportunities for community based organizations, looking at the budget to see where we can make budget adjustments to make sure that, like, Medi Cal programs are still made available, that the WIC programs and, you know, are made available.

Right now, we're seeing a huge gap in resources for our unsheltered population, and that is also creating an impact, especially for those who are unsheltered and pregnant and, you know, trying to find sustainable housing, you know, having transportation to get to appointments. It's I hate to say it. It's a mess right right now what we're seeing in communities. And so really hoping that we can work together, as a collective team to address some of the situations and issues that folks are facing in community.

Definitely plus one to the points that you have lifted. It's it's a time of deep uncertainty right now for us. You know, over 80 of our patients are on Medi Cal or Medi Cal programs. And so this could have a real direct impact to folks since it's important to make sure that public assistance programs remain accessible, to folks that remain as robust and more robust than they currently are.

This this work, is is noticed by our communities and the difference of whether or not they can access health care, whether or not they can afford, health care.

I think also as Kim mentioned that there it cuts to health care and education as well. And so especially in the example I mentioned of having to cut from 28 to six staff, that's also community relationships that are lost because of lack of resources to maintain them. And so it's a health care cut. An education cut is actually a cut to an ecosystem. Right?

So the relationships we have with legal service organizations, with housing support organizations, with social work organizations across the board lose this connection, and we lose the resources to, in turn, continue to build as an ecosystem of social and health support.

And we lose that trust because folks don't feel like they can come to us or Or that, you know, they can trust that that that resource is gonna be there.

Quessa, did you wanna add anything?

Yeah. I will also just add number 1 plus to everything both. Sofia said they ate. I will also say that there's not only like the lack of education from outside sources, but also like, looking at our chaya, compliance among schools, we're we're also seeing huge gaps in what, structures and systems are supposed to provide, and not a lot of oversight into, how they're doing what they're doing.

And so, again, I I wanna plus everything that Kim and and Sofia have said because they really are working within those communities within health care access.

But for us, a lot of the work that we do is is, boosting, our coalition work and and policy endeavors. And so, I will ask legislators, I guess, to really, like, informational hearings like today, really look into the community and ask from folks working within those spaces what the community needs, ask the community what they need and and really make a good faith effort to to put dollars behind what we say we're gonna do for for our people.

Because as Kim said, it's a mess out there.

Assembly member?

I just wanna apologize for, coming late, but really appreciate the presentation that I did catch and looking forward to continuing to kind of update on some of the pieces that I missed. But I did just wanna echo I think it's Claire. Clarissa, yep, got that wrong. I was up there. I was close.

But there's a there's a a a page, the call to action that you presented, and I think it's so important to talk about and to think about at every moment. Like, who is missing from this table, and how do we ensure that every time we're making a decision, policy, budget, as we're, you know, really sitting down to talk about some of these things. We know that there are some of us who are grounded in community in that way, and that's how we always move.

But that doesn't mean that we know everything or that we are the experts or that we capture it all. It's so important to have spaces like this that really do that, you know, thinking about who's shaping the solution.

Those who are closest to the problem should be shaping the solution. And when we recognize that we don't have all the answers, I think that's when we can take a step back to really bring folks in. But I just really appreciated thinking about those pieces. Like, does it build community trust? Is it able to reduce structural harm?

Like, that's how we should go into all of this work, and I just really wanna thank the, Chair of the select committee who's really pushing us to think about how we, deal with, push forward when it comes to Latina inequities, but overall inequities that impact all of us, as well as our our black, community as well. Thank you.

Thank you.

Thank you so much. I think this also, for me, lifted up, you know, just these questions about underfunding solutions. I was I had a conversation in my own community about a very successful teen parenting program that the state funding is gonna be sunsetting. And their understanding was that because we've been successful in reducing teen pregnancies and the necessity for supporting these young parents that the program is seen as no longer needed.

But But then I think about Sofia, you bringing up just some of these cuts that are happening and this education for our youth that's gonna be taken away.

And so in addition to us getting the chance to look at the history and the present disparities, just thinking about those disparities that are be gonna be coming because of what's happening right now. So just thank you so much for grounding us in community, reminding everyone that, you know, community solutions do exist. We have amazing partners that do need the support to carry things forward, and I appreciate the the bills you flagged and the homework that you assigned us.

And I ask that you continue to stay engaged so that we can move policy forward that really solves these clear issues that shouldn't exist in our communities. So thank you so much.

Thank you. Thank you. And now, we're gonna move to the second part of our hearing this morning where we're gonna specifically focus on maternal health, from prenatal care through delivery and postpartum care. This is where those disparities we're talking about are often most stark and measurable, and we wanna be straight up in this room that California has made real investments here, and we're gonna hear about them.

But we're here to honestly talk about where those gaps in investments have yet to close the gap because both things can be true, and we're here to have an honest conversation about that.

So I'd like to invite representatives from the California Department of Public Health and the Department of Health Care Services to walk us through where we're the state stands today, the data on disparities, and the initiatives currently underway to address them. I wanna welcome Matthew Green with the California Department of Public Health and Chris Esguerra with the California Department of Healthcare Services.

Alright. Well, good morning, madam Chair and members of the committee. Thank you so much for inviting me here to speak with you this morning. My name is Matt Green. I'm with the California Department of Public Health as the deputy director of our Center for Family Health.

I'm here today to provide information regarding some of our efforts related to advancing reproductive health and improving maternal health outcomes for women of color. As, Black Women for Wellness pointed out, despite great strides in improving overall maternal and infant health outcomes, racial and ethnic disparities continue to persist. Some of this data you've heard, earlier today, but black birthing people continue to experience disproportionately higher rates of pregnancy related complications, maternal mortality, preterm birth, and infant mortality.

Black birthing folks are three to four times as likely in California to die of pregnancy related causes than any other racial ethnic group. And for instance, the pregnancy related mortality data show that about a hundred of a 100 thousand births among Black birthing people, fifty six point five die from pregnancy related causes.

The next highest impact is on Hispanic Latina birthing people at a rate of about eighteen point four pregnancy related deaths per 100,000 births. So that's a third of the rate of black birthing folks. And then, white birthing folks are experiencing a rate of about fifteen per hundred thousand, deaths per 100,000 births. Life threatening childbirth complications are also highest among black birthing people, and as you heard from Kim, black infants are twice as likely to die as other infants by their first birthday.

These inequities are driven by structural and systemic factors, not just individual behaviors, and require intentional equity focused solutions.

In addition to longstanding programs such as the Black Infant Health Program, which was established in 1989, the more recently launched Perinatal Equity Initiative, and the Pregnancy Associated Review Committee work solidified by SB65 and the or the California Mominibust Act of 2021, CDPH has been deepening our focus in this area. Black infant health and perinatal equity initiative programs use evidence based and community informed models such as group peer support and prenatal care models, fatherhood and partnership supports, as well as community based doula services.

Black infant health evaluation data has shown positive impacts of the group based peer support program including decreases in depressive symptoms and food insecurity, increases in knowledge around safe sleeping practices, and support received by the participants. Preliminary PEI or Perinatal Equity Initiative data also shows promising success. So for example, across one fiscal year, of the 900 participants of our fatherhood partnership program, approximately eighty five percent improved reported improved knowledge, support, involvement, and co parenting skills with the birthing person.

Another intervention of the perinatal equity initiative involves doula, community based doulas, and of the 30 387 participants of that doula program, ninety six percent, reported that the doula contributed positively to their birthing experience. Ninety seven had also initiated breastfeeding, and eighty six had completed at least one postpartum visit. The centering or group prenatal care interventions have also been shown to be immensely positive with impacts on breastfeeding, preterm birth, and low birth weight outcomes.

To build on the successes of these models of black infant health and perinatal equity initiatives and further examine the opportunities for us at CDPH to address birthing disparities, CDPH partnered with use University of California San Francisco, Black Women for Wellness, and a group of birth equity leaders from across the state to co develop the Centering Black Mothers in California report. This report, which was published in 2023, documents persistent inequities in black maternal and infant health and identifies structural racism as a primary driver of these disparities.

To quote doctor Joia Kreher Perry, who's the founder and president of the National Birth Equity Collaborative, race is not a factor in maternal health. Racism is. The report elevates community informed recommendations and links structural racism to birth outcomes disparities in three ways, neighborhood conditions that are influenced by discriminatory policies, two, chronic stress and weathering, and three, lack of access to high quality respectful health care.

To build on these findings and recommendations of this report, in January 2026, CDPH launched the Advancing Black Birth Equity Together in California action plan. This two year action plan is currently underway and translates community recommendations into a coordinated department wide commitment to advancing Black perinatal health outcomes, starting with our CDPH maternal child adolescent health division.

The main purpose of this action plan is to align departmental efforts around shared priorities that improve the health and well-being of black birthing people and families while laying the foundation for sustainable long term systems change. This action plan was intentionally co developed with black leaders, community organizations, public health experts, and individuals with lived experience.

And through partnerships with organizations such as the California Coalition for Black Birth Justice and Liberation by Design, alongside a group of statewide advisory advisers, Blackbird equity leaders across the state, as well as internal CDPH team members, this plan reflects the priorities and expertise of the communities most impacted by these inequities.

These co developed strategies focus on strengthening culturally responsive services, advancing policy implementation and data improvements, fostering authentic community partnerships, and investing in community based solutions that address the root causes of inequities, including social, economic, and environmental conditions that influence birth outcomes.

Implementation has been ongoing for about six months now, and our progress has included initiating an internal black health equity assessment of all of our MCAH programs, embedding additional resources to advance data in action through creation of a work group and inventory of related data indicators to inform the cocreation of a data resource with community partners, supporting University of California San Francisco to launch a community innovation pilot award program funding additional perinatal health innovations across the state, as well as building additional structure and engagement with our statewide advisory group of Black birth equity leaders.

We are also facilitating local community of practice sessions with our local health jurisdictions for peer learning and peer support around implementing birth equity strategies across all 61 local health jurisdictions. We also spread awareness of the department's efforts through a variety of communications, including a webinar, during Black Maternal Health Week of April of this Year. A defining strength of this plan is its commitment to community collaboration and centering those most impacted.

The plan centers partners implementing perinatal health services to Black birthing people and promote shared learning, meaningful peer support, and collaboration at the local level. To sum up, the action plan supports California's broader reproductive and maternal health goals by advancing equitable culturally responsive perinatal health services and by aligning best practices from initiatives such as the Black Infant Health Program, the Perinatal Equity Initiative, SB 65 or the Mommy Bus Act, and many other impactful partner initiatives.

This plan aims to ensure that efforts to improve perinatal health outcomes are coordinated, evidence informed, and focused on achieving equitable outcomes for those who continue to experience the greatest disparities. We're also excited to be partnering closely with Department of Healthcare Services on multiple shared goals in this area. In particular, the plan highlights our shared commitment to increase access to doulas and midwives and underscores our ongoing collaborations related to the birthing care pathway and other medical policy shifts impacting maternal and infant health.

Thank you so much for your time today, and I'm happy to take questions as appropriate. Thank you.

Thank you. I do I have one question. Sure.

I have couple questions, but you you lifted up some of the data we started talking about in the first panel in recognizing that racial disparities in pregnancy related mortality narrowed somewhat in some of the data that had been provided. The black white gap still persists. And we already mentioned, right, three to four times higher for over a decade. So what specific state investment or policy change would CDPH point to as most likely to close that gap versus, like, further narrowing it modestly?

I think there's a lot of answers to that question because it is a complicated issue. But I will say that the Centering Black Mothers report, those three main areas that it identified in how structural racism operates In terms of, birthing outcomes were the three pieces of neighborhood conditions, living conditions essentially, access to high quality respectful health care, and then addressing chronic stress and weathering related to discriminatory conditions.

And thank you for sharing that quote about it not being racist. It's racist. Doctor Kreher Prairie is a is a legend of this year. Yes. The other question I had was that in the recent data, it showed that sixty percent of pregnant related pregnancy related deaths in 2020 to 2022 occurred after delivery.

Doctor Kreher Prairie is a is a legend of this

Yes.

A shift from earlier years when it was delivery was seen as, like, the main point. What does that shift mean for where the state should be directing the postpartum monitoring and follow-up care resources? I know you've gathered folks for those answers.

Thank you for that question. It's important. We really are seeing a need for continuity of follow-up around the the postpartum period. And so as you said, the data points to those seven to forty two days after pregnancy being the highest risk of death in this case. What we're looking at in some of our programs, as I mentioned, data shows that linkages to those postpartum visits are very important.

So ensuring the continuity of care and support throughout the perinatal journey, including up to six months, after, after delivery. And for example, our black and different health programs and our home visiting programs and others follow the pregnant folks and their their family up to two years depending on the program postpartum to ensure those linkages and things like that.

Yeah. Which I think just again recognizing, right, in those, like, seven to forty two days, like, they're preventable deaths and access to care speaks back to the first panel about community clinics and even transportation being tied to all of this

Absolutely.

And the ability to access back here.

Absolutely. And that's the we're seeing the highest deaths related to about four different factors, cardiovascular disease, mental health, infection, and, you know, some of the other things are related to birth complications. So those are some of the the the four highest cause of death.

Thank you for sharing.

Of course.

Doctor, you're next.

Alright. I believe I have some slides. Alright. Madam Chair, so we are going to go through and really talk more and focus on the structural components. And and I really resonate with the comments earlier about creating an ecosystem, and that's what we're gonna go through.

So the next slide, please. So we'll go through really understanding what this is all about and components of it, and in particular, our birthing care pathway, the postpartum pathway concept paper, as well as our transforming maternal health. Next slide. So at the Department of Health Care Services, we have had this goal, our bold goals of reducing inequities. And we are in the midst of gathering all of the data for measurement year 2025 to be able to report that.

So we're not there just yet, but we will get there. So next slide. Going into our birthing care pathway, and the next slide. From a structural component, which what you've heard earlier and you you've seen the data, you've heard about the data, it to the question earlier, there is no one solution to truly address these disparities and to begin to narrow them.

We need to understand all of the components of these structures and identify this entirety of care and pathway and and how we begin to tackle all of these pieces.

Hence, the work here in this burden care pathway to really think about pieces in the comprehensive way from a health care perspective, physical health, behavioral health, health related social needs. And so you've heard elements of that, and we're gonna be bringing that those pieces together. The goal here as you see the slides is reducing that maternal morbidity and mortality and address the significant racial and ethnic disparities that persist, unfortunately. Next slide, please. This isn't something that we thought up in isolation.

This is a community effort, and I think the department is very proud in having brought together a lot of these voices. These are the same themes that you have heard earlier today, the trust, feeling respected. How is it that folks don't experience discrimination? How is it that you are able to navigate a very complex, unnecessarily complex, but very complex system? How is it that when I need help, specifically mental health help, it's easy to find?

It's it's very difficult in many communities. And I may be covered in Medi Cal, but I actually don't necessarily know what that means and what is actually covered. So how do we address all these pieces? So very fundamental, and this was very helpful in really understanding what we needed to do. So we took at it, next slide, and really trying to look at it from a policy perspective of which of our policies support this, which of our policies actually inhibit this.

And it it it took a lot of good work internally to then start asking those questions from that perspective. And we've learned a lot of things, and we've actually done a lot of changes. So we are in the midst of changing and updating 42 policies. We you'll see the progress in a little bit.

But you see here these elements of trying to address things such as access, recognition of very specific types of health care workers, doulas, community health workers, as actually part of health care and making it easier for them to be a Medi Cal provider and actually do the work and get paid for the work.

Just a quick little note with, for example, community health workers. Historically, prior to community health workers being an actual benefit on their Medi Cal, they were grant funded, and those programs may go away when the grant goes away. This is sustainable because now it's paid through Health Care Dollars, paid through Medi Cal.

And so that again, as we talk about the structural building of trust, having your person by way of a community health worker or promotora, whatever we're gonna call them, in a sustainable way is part of that. The recognition of and easing the ability for doulas to become a Medi Cal provider is huge.

It addresses actually a disparity because in other areas well, actually, you have to be able to have money to pay for your own doula. We're making this a benefit, and we have made it a benefit. Now it's the how do you make it easier for a doula to become a Medi Cal provider. There's these little pieces that get in the way, and so we'll we'll get into a bit of that.

So these are just some of the examples of how do we start tackling these pieces of the structure and some of the fundamental components, data, data quality, how we actually partner together.

Although some of these pieces are actually quite new, and how do we do that? Again, back to the community effort. And so we have done some things. We have more to do, and so you see that there. And in the next slide, you'll see the progress.

We have 30 policies that we were able to complete. One, I have to make a note of, which was fascinating. There were a series of policies to the managed care plans starting in the late nineties to as recent as 2025. They all tackle maternal health in some way or another. As you can imagine, these things kind of just built over time, sometimes contradictory, sometimes confusing.

We took it all and just said, look. Let let's make it make sense and recently released that earlier in the spring this year to make it make sense. So that was one huge set of policy all plan letter for managed care plans for an accountability perspective. And if we go to the next slide, you'll see some other examples. So Matthew Green talked about that post delivery, postpartum, really high risk time.

One of our areas in working with our systems, our health plans, is really thinking about the transitions of care and transitional care services. It's a very sensitive time. How is it that we hold the system accountable to actually making sure it's able to support that individual postpartum? And then really thinking about, when we think about the journey around birth, we think of the first the trimesters, the birth itself, but we really also have to in include that postpartum period, both immediate and even a year after.

And how do we think about this from a truly holistic and community oriented perspective?

That transition is one of them. However, again, these interesting things that get in the way is this idea here at the first bullet of a standing recommendation for doula services. We had to just get rid of that barrier and have to have it. And so that way, it is something that is known and something that, we're able to do.

Number of these things too also include equity in payments, in terms of our rates to maternity care providers and really rationalizing what is it that we value in terms of the care and the care process.

We still have more to do. So in the next slide, we are looking into, some more things. And and, again, this isn't something done in isolation. This is us going back to the community and getting more feedback of what else can we do and how do we think about further moving this and further thinking about this as an ecosystem approach, as a structural approach. So I'm gonna switch gears a little bit into the next slide.

There are postpartum care pathway, the concept paper here, and into the next slide. So this was a lot of folks coming together. Again, this isn't something that you can do alone, and this is where the our partners here came together to really think about this overall and what are some ideas? How do we wanna address this? Into the next slide, you've seen these statistics.

They're not great, and we know we can do better. Madam Chair, you asked earlier how do we measure trust and whether or not it's actually working from an accountability perspective. Trust means those equities disappear because now we have a system that is trusted and behaves in a way that is trusting, for the folks it's supposed to serve. No need to go into this data. You've heard this before.

So we'll go into the next slide. The goals here, it makes sense. Common sense, but it's a lot of work. Right? So let's reduce the morbidity and mortality.

Let's address the significant racial ethnic disparities. You've heard a number of these pieces of what folks the community has already identified. How do we reduce stress? How do we reduce the trauma? How do we reduce this isolation that can occur?

And how do we increase access? How do we have a better experience that is community oriented and community centered on that individual? So next slide. So this recognizes those pieces of the per pregnancy journey that I described. Right?

There's the care that needs to happen earlier on. There's the actual labor and delivery. There's the immediate postpartum, and then there's the longer term. And then how is it that we think through some of these pieces? And so those policy components start to address those and that we have already completed in the birthing care pathway.

Now this concept paper came out and is it complementary and informs a lot of the birthing care pathway efforts. Now we can impose policy. We can do all these things. We also have to be thinking about how we pay for this. So in the next slide, we'll talk about briefly the transforming maternal health model.

So next slide, please. What is this? We have a lot of acronyms. So this California was selected, one of 15 states to implement this model. And the idea here is to rethink how we actually pay for this entire experience and thinking about it from a value perspective.

So talk about accountability. So right now, payment is, hey. You have a visit. We pay for it. You have the delivery.

We pay for it. And then, hopefully, you have the visit after delivery, and we'll pay for it. We want to get that connected. We want to anchor that in outcomes and accountability and value, and it's gonna take time. So we're focusing on these five counties, Fresno, Kern, Kings, Madera, and Tulare Counties, and we have $17,000,000 in federal funding to to test this out.

What does this mean in context with the birthing care pathway? It's our next slide. These two are complementary to each other. The birthing care pathway is work that we know we can do already. How do we think about this strategically in terms of our policies?

The transporting maternal health aligns and then allows us to test different models, different payment models, different infrastructure. What do we need to do to invest? The next slide, please, tells us the time frame. So we're just in the beginning. And part of this beginning is actually we're our partners.

And next slide. It's a community effort. I'm not gonna list everybody here, but as you can see, though, we need to have a community effort in order to do this, and it needs to be informed by the community in order to think through how we're really gonna pay this differently. Next slide, please. So as you see, it's in early phases.

We're doing a lot of gathering of folks, making sure we have a lot appropriate engagement, understanding who needs to be in the room, how we actually engage with each other, and we'll be submitting that to CMS coming October. So with that,

questions? The

birthing care pathways report is just so helpful. It actually inspired one of the bills I'm carrying around lactation support and the fact that Medi Cal eligible members to back to what you said at the beginning, aren't even sure what their coverage means or what it comes with, and it's so inconsistent in different spaces and places across the state. And it you know, a lot of times, things come back to funding. Even your you mentioned how we pay people.

Like, that was a component we had to discuss.

How do we have qualified folks to support these mothers in that moment? But even just being able to disperse payments is an administrative function that requires funding. And so I guess I wanna start with the question that we ended with in the last panel, which is all of the federal changes happening right now, all the all the reductions in federal funding, and the increase in uninsured. And we know that Medicaid just you know, black, Latina, and Native American women are relying on this.

What is the contingency plan for for both your departments when it comes to these reports and how you're gonna support this work moving forward?

It's a great question. So with regards to as you're saying, with the cuts and the financial challenges as it relates to Medi Cal, the the wonderful thing about the birthing care pathway, it is is largely independent of funding. This is structural work and policy work that we are work we are using to really change the frame and incentives of behaviors that allows us then to unlock and to really remove historically unnecessary barriers. So lactation consultants, for example.

So prior to this role, I was working at a Medi Cal health plan, and I recall getting a question from Department of Health Care Services of how do you promote and pay for lactation services?

And internally, we checked. We were like, it's not a problem for us. But we had figured it out in terms of, yes, we tell our physicians exactly how to go do it, and sure, you can go ahead. You had you need to do it under you know, do the whole process straightforward

For us.

Turns out it wasn't straightforward in other places. And being able to spread those insights and best practices, even in that, those little details matter because it matters in terms of access. What you don't want to happen for any one individual is someone to say, oh, we don't do that because we can't get paid. Because they didn't know how to get paid or unlock that ability to get paid.

So there's a lot of that work in terms of awareness and really going down to that next level from policy and framework.

The this road map is also as and as we know, when we set policy, it's gonna take time for it to work and go through. So our goal is to complete all 42 policies by the end of the year and then start looking at the accountability components. Again, that's independent of funding and so allows us to do a lot of this this work. And so I think we are in a good place.

The postpartum pathway itself, again, aspirational in nature, and yet we're able to do a lot of the pieces there already and start to address.

That is not to say that, yes, this is a stressful time. And so all the more, where I think it has to be an ecosystem community based solution in order to really weather this and to go get through it in a way that we're still attacking those disparities.

Yeah. And I will I will underscore, the idea of supporting the ecosystem. We all have an opportunity to support this broad ecosystem, and CDPH does remain committed to ensuring that all eligible Californians continue to have access to all the services that we provide. We are monitoring and continue to monitor federal developments and any offense you know, potential effects on participation in all of our programs. And we do remain cognizant of the shifting legal and political landscapes and work to ensure access to such programming by eligible individuals in compliance with all state and federal laws.

And we do remain cognizant of the shifting legal and political landscapes and work to ensure access to such programming by eligible individuals in compliance with all state and federal laws.

Thank you. The my last question was just about the postpartum pathway concept paper, about that postpartum period that's so critical. How do you plan or what what is the plan around maintaining Medi Cal coverage with everything happening right now, with challenges navigating your redetermination and these eligibility, challenges in that. You know, you talked about how do we coordinate these, like, phases so they talk to each other, but now we have this other element where people can be tossed off of care. Right.

So what do we do? We know it's critical.

Yes. Yeah. And and and you're right. The interplay here for this particular period, you know, we touched on the care component, and yet you want to make sure your coverage is is is there or else it's going to disrupt the actual care itself. And so the nice thing, at least for California and Medi Cal, is that for, those individuals who are pregnant and twelve months postpartum, women are not subject to the work requirements and so or the six month renewals.

And so that period is protected from a

coverage perspective that allows us then to focus on making

sure that the care then to focus on making sure that the care process is actually improved and better again from the transitions perspective to the follow-up. And, you know, I I'm a psychiatrist by training. Part of my training and my clinical experience actually was in this post pre it's a pre to three program in San Mateo County. Really cool work. And the behavioral health needs during that time are so sensitive and important to be able then to have a system be able to support.

We also need a person in the community to be able to you know, when someone raises their hand or be able to be noticed that you might need help. So, hence, again, the overlay of the community health workers and the doula that can go past the delivery. So, again, from a coverage perspective, that's preserved to twelve months Allows us to focus on, okay, what are these other care components that need to be coming together?

Yeah. That's really, really helpful to know. And I think just what you laid out is these are great goals, and it's wonderful that you're tracking and measuring your progress on the goals. And I think it's a great starting point for the rest of of the panel today to talk about, you know, what what's gonna happen in the room now. How do we ensure that these, you know, goals are showing up in practice and clinical settings?

So I wanna thank you for for being here today. Please stick around in case we we have any more questions for you. Sure. And I'd like to invite doctors Kelly McHugh and Nicole Economo with the American College of Obstetricians and Gynecologists. These are our OB GYNs who are gonna talk to us about the point of care and what more needs to happen.

Good morning, and thank you for having us today. My name is Nicole Economo. I'm an obstetrician and gynecologist here in Sacramento. I trained throughout California in Los Angeles and San Diego. And right now, I work on labor and delivery, provide prenatal care, gynecologic care, and abortion care, including at multiple planned parenthood clinics in Northern California.

I am here today on behalf of ACOG, the American Congress of Obstetricians and Gynecologists, to discuss the health equity initiatives and programs that we have initiated on the state level for our OB GYN colleagues. Next slide, please. So I'll talk a little bit about some of the reproductive health equity initiatives that we have developed here in California. Next slide.

I am one of the co chairs of a committee or task force on collective action advancing respect and equity or the Care Committee, which is focused on DEI efforts.

And our mission is to empower our members and our healthcare partners to transform the delivery of obstetric and gynecologic medical care into clinical practice that both respects and celebrates the diversity of experience of our patients. And we aim to accomplish this by creating an inclusive and collaborative professional patient care. Next slide, please. This committee was founded in 2020. What a time to have found a committee.

And since that time, we have put on a number of webinars for our members. And this is just a selection of some of the webinars that we have available. So we host these webinars live, but they're also recorded and on our website. One we had on immigrant rights on how we can protect and support our patients, especially in the wake of many ICE raids and patients being afraid to come to clinic. So what are the protections that we can put in place for our patients?

We've had webinars during Black Maternal Health Week about advancing equity, had webinars on how do we foster diversity in clinical research and clinical trials and including more women, pregnant women, and women of color in these trials. On the right is a snapshot from a webinar that we had on racial disparities in health with Doctor. Cara Bridges who is an American law professor and anthropologist that specializes in the intersectionality of race, reproductive justice, and law. And many of our presenters are not physicians.

So some are lawyers, some are community organizers, and we do this intentionally because we can hear from other physicians, but we don't get a lot of this training in medical school.

So we bring in other experts who really have focused a lot of their work on equity and anti racism in trying to tell us how can we best create these equitable environments for our patients. Next slide, please.

So we bring in other experts who really have focused a lot of their work on equity and anti racism in trying to tell us how can we best create these equitable environments for our patients. Next slide, please.

Hopefully the PowerPoint is working, we can go to the next one, thank you. One of

the big initiatives that our committee undertook in the last few years is something called the CLEAR initiative, which is a continuous education effort to promote system, systemic equity in health care in the health sciences. These are foundational resources that we curated and put together for our members to further OB GYN's understanding of power, privilege, oppression, and equity. And these are supposed to be level setting and foundational understanding. So these are very basic. What is health equity?

What is racism? What is systemic racism? And how does this impact our patients? And how does this contribute to poorer health outcomes? And it's really understanding some of these concepts before addressing the manifestations in medicine.

And this model is bringing awareness to OB GYNs and then the medical setting and health care systems. And we had this, roll out to different programs in different hospitals throughout the state of California a couple of years ago, to help people leverage these resources to make changes at their institutions. That was the goal through improving equity curricula. And we really wanted to have this educational resource that we put forward. So we'll go to the next slide.

After we rolled out this initiative we encouraged people to engage with some of the resources and then we sent out a survey to get feedback on what they thought about the resources that we had curated. And some people said that a lot of new information was provided to them, which was very much our goal. Wanted it to be implemented to all departments and training programs and really appreciated having a repository of resources to then go back to and share with others.

And one of the webinars that we had included in this initiative really helped to have concrete steps to take moving forward, and that's what we really wanted is we wanted to move from being performative to transformative in our work. Next slide.

Right now, we have received a grant from the ACOG Care Delegation, and we are actively creating, the ELEVATE toolkit, which stands for equity, listening, empathy, and value aligned trauma informed excellence. And we are working with our colleagues in Georgia and North Carolina to cover the Southeastern Part Of The United States as well and working with an educational consultant to develop an app with modules and interactive learning scenarios on health equity and respectful care.

I I wish I can create some acronyms like that. You know? I'm like, how the hell did they do all that and make it sound so damn cool? Man.

I have to say we did have some help from AI in creating the name of the toolkit. I'll be very transparent about that. But we went through several iterations. So we really wanna make some of the existing resources more accessible and more engaging so people are not just watching a module or reading something, but really interacting with it and challenging their own understanding. So to come more of this to come and we're hoping to roll this out hopefully in the next year. So I'll turn it over to Doctor. McHugh.

Next slide.

Hi there. I'm Doctor. Kelly McHugh, an OB GYN and also in the Sacramento area. I sit on the executive committee for ACOG California, and part of my experience has involved leading a very large department of more than a 120 OB GYNs, midwives, nurse practitioners, etcetera. In my experience, I found that the education about racism and implicit bias is absolutely critical to recognizing that there is a problem, a health crisis really, that needs to be addressed.

But in order to close the disparity gaps, it it has taken more it takes more than just individual action. In order to get something accomplished, you really need a team of people in order to achieve a goal. In order to do that, you have to have a goal. And you've gotta get people on board with the goal, and then you have to have a strategy of how you're going to impact the goal. It's no different in places like labor and delivery and postpartum.

You you need to have the team of people. You need to get them all moving in the same direction and working together in order to get an impact. So in medicine, we do this a lot through what we call quality improvement projects. And California, the state, incentivizes already hospitals to do certain, quality improvement projects already. Things that come to mind, infection rates, decreasing primary c sections.

I don't know if you've heard of any of this work. So one potential policy proposal would be that we could work with hospitals that have maternity services on projects where one or some of their quality improvement projects are specifically targeted to closing equity back gaps where that is the goal. So we can figure out who are we leaving behind and how do we not leave them behind. The next slide. So in order to do this, the quality improvement projects would need to be equity focused, obviously.

They would need to be data driven. It's gotta be specific to the entity so that people on the ground recognize this is happening here. It's not over there. It's right here in our own place. You've got to involve the impacted individuals in sorting out the what the solutions are, and you have to have measurable and transparent outcomes.

Next slide. So this sounds very difficult, but the the great news is that we already have the data. The data is the hardest investment to make, but we've already got that. So the California CMQCC, the California Maternal Quality Care Collaborative, all the hospitals turn their data in on an annual basis to the CMQCC. The CMQCC then takes that data and organizes it in a way so that as the hospital, you can log in and you can get your specific data.

How am I doing on preterm birth? How am I doing on this? How am I doing on that? What about hemorrhages? How about transfusions?

But then you can also filter that data already based on race and ethnicity. Well, how am I doing in this arena? You can compare yourself to other hospitals in the in your local area, but you can also importantly compare yourself to other, like, level one hospitals that do low risk births versus just the high risk hospitals that have, you know, all commerce, all of the the difficult medical situations. So you we can already do all of this. Next slide.

So what I could see is having this change. How do we make this happen? How do we change the disparities? It's at the institutional level, each institution. And you what you would do is you would have, like, a the local delivering entity take a look at their own data through CMQCC, develop AQI project aimed at closing an equity gap in their location.

You involve the affected patients and communities. You got to involve the physicians, the nurses, the midwives, the doulas in the project. Then you implement your solution approaches, and then you report the results. And you probably are gonna need to do iterative chain in my experience, you you you don't you don't hit it the first time. You have to keep, like, redoing it over.

But but that's the way that I have seen any any chipping away some of these disparities actually happen on the ground on labor and delivery.

Does that conclude your presentation? Yes. Okay. Thank you so much. I I have a question about, you know, these these interventions that are happening at the institutional level and just learning from them.

And I wondered if if you're aware of any evidence based interventions on, like, the labor and delivery floor that have actually moved an outcome positive outcome in addressing the disparities we're talking about today for, like, black, Latino, indigenous women.

So, yeah, I was created a project a similar project like this is which is why I know that you can do all of these things if you are so incentivized and if your institution is interested in doing so. And the I'll tell you a little bit about what we did just so you can kind of envision what this would look like.

We noticed that one of our big gaps had to do with our our black women who were getting transfused significantly more often than our non black patients. And so we said, okay. What's going on here?

Why is that? And it was really, like, this time to peel back to see. But the amazing thing about the CMQCC data is, as the leader in that, in that department, I could access medical record level detail to figure out who were the people. Let's go back and look. We did chart reviews.

We set up questions. We had our DEI committee and other physicians, non OB GYNs, reach out and interview those people who were impacted in this way. And we said, you know, we have this whole list of questions. Tell us what, you know, your thoughts were. It turns out that many of them were pretty anemic coming into labor and delivery.

Of course, they don't know they're gonna lose five hundred to a thousand cc's of blood, like a liter of blood

At their delivery. And so if you come in low, your chances of getting a blood transfusion is higher. So we were asking them how can we like, what how how did we miss the boat here? What did we do? And we came up with all sorts of solution approaches, following people, having somebody go through and have lists and double check.

Hey. Did you get your labs drawn? Just just following up to make sure and making the connection that if you're low and you're anemic, you are at increased risk for a blood transfusion. We we implemented other things, like if somebody comes into labor and delivery and we noticed that they're, like, I don't know, twenty eight weeks and their blood count is really low, we can offer them IV iron. We're never gonna catch up with that oral iron at this point.

So why not we're there. And getting across some of those hurdles is a lot I mean, it sounds like, well, duh. But it can be very difficult to get everyone on board to say we're gonna utilize this space in this expensive area to go ahead and just administer that treatment right now because it's gonna help in the end. And, Assemblymember, I know you had talked about evidence based interventions. And unfortunately, there is a lack of evidence on care delivery models that directly decrease obstetric health disparities. The most actual evidence we have is on group prenatal care, like centering pregnancy, which other presenters have talked about. And that's probably due to increased patient clinician time. It doesn't address what's happening at the time of delivery.

And that is probably because there isn't going to be a one size fits all approach. I think it is going to come down to individual hospitals and departments really evaluating what are their patients' needs Or the patients that they're seeing.

And do you feel that institutions are open to this diving into their data, identifying solutions? Very much.

Could be and definitely. So it ranges.

You have to have a champion at your institution. I think we can identify champions that really want to do this.

Champions are everywhere. Yep. It's a matter of getting the the big ship to turn.

Yeah. Are there any state licensing or scope of practice or, like, we talked about reimbursement practices that are currently maybe working against equitable maternal outcomes intentionally or not?

So I would say that we heard some talk about this earlier today. It is so important as a society that we value maternity services, And maternity care needs to be considered as part of primary care. There are certain areas, in things that we're doing that that says, oh, if your care is provided by an OB GYN, it's not part of the primary care spent, which Because specialty. It devalues Care for women. Because when you're prioritizing one thing, you're you have to be deprioritizing something else.

So that's one issue. In 2024, we had budget increases for primary care services and obstetric services increased to 87% of Medicare. It is absolutely critical that reimbursement for these services continues and not only can not only continues but increases because it still doesn't cover all of the cost to provide the services. You know, we've had 50 labor and delivery closures since 2012 in the state of California.

It just the the the amount the reimbursement is low enough that in the lower volume hospitals, they can't they can't make up for they can't make up for that.

Yeah. And so then they close. And what happens then? You you impact anytime you the resources become limited, who gets impacted first and hardest? People that we're here talking about advocating for today.

I think that that is actually maybe my last question is about that. When we're losing care separate from people losing health care access, just the availability of care in, like, our rural communities or even in LA when I was seeking care and they explained to me the shortage of OBs and why there was a struggle to address needs. We heard from our first panel about, like, needing more, even clinicians that look like the communities we're talking about needing to serve to close these gaps.

So what can us as a legislator do to help in supporting these residency programs or or the pipeline that we need to address some of the things that have been lifted up?

That's a great question. It's the answer also is not an easy one sentence answer. It's always helpful to support people from underserved areas and from underrepresented racial and ethnic groups who are seeking to become part of our health care workforce. So but that support has to begin very early. Physicians, as an example, complete four years of undergraduate education and then four years of medical school followed by three to five years of residency training.

It is a lot of training. During this time, it is very common for people to acquire over $300,000 worth of debt. And so there are many opportunities for support. Prior to medical school, there's, like, guidance mentorship, test prep to help people get to the place where they can get into medical school, and then, of course, scholarships are helpful. In medical school, there are things that could that can be done and that are being done.

As an example, UC Davis uses a holistic application review process where they don't just look at the scores of the individual. They're also looking at the person's background and, languages, other languages that they might and they're they're evaluating those as as important as, some of the other things. Their prime program prepares people for providing care to specific underserved Californians, including Latina, rural people, or urban underserved. And then there's another thing that happens.

The ASPC program streamlines the the timeline that I laid out earlier so that there's three years of undergraduate, three years of medical school, then residency.

But you're still only you know, you're cutting two years out, but it's still a long it's still a long time. And then in residency, you had mentioned about, like, you know, what can you do? Well, GME funding is, like, huge. Graduate medical education funding is difficult to to come by. There's the Song Brown and Cal Med Force programs that prioritize funding programs that are in underserved areas and those that have a high percentage of graduates from underrepresented communities.

Healthy Rural California is a family medicine program from Chico that was state funded after the, Camp Fire to increase access. And then I'll move on to the last piece, which is post residency. Loan repayment offerings, are huge. You offer loan repayment for people who are practicing in underserved areas because that debt that you're taking on coming out is just ginormous.

And with some of the changes that have happened with the loan structures, used to be that the interest deferred until you're done and now it just, like, it just exponentially increases.

Thank you. That's really helpful, and I think it just brings it back to just the different directions that these federal funding cuts are gonna hit Yeah. This issue and how without diving deep and finding some ways to find solutions. Like, we're gonna continue to see a lack of clinics in rural communities, which will impact the maternal health outcomes of the women there. And so it's just really helpful to get your perspective in this conversation.

So I wanna thank you for joining us today. And I think the the workforce component is a part of our next speaker, and I'd like to welcome Xiomara Pena next Thank you so much.

From Hispanics Organized thank you so much. From Hispanics Organized for Political Equality. This is our final presentation, and it's gonna bring us back to the voices of the women living this reality. Hope's California equity and maternal health report draws on the direct experiences of hundreds of women across the state. And I think it's a very fitting way to close this panel, grounding everything we've heard in data and policy back to lived experience.

So thank you for being with us.

Thank you.

Thank you, Chair. Thank you, members. As you've heard today first, I'll start with a quick introduction you introduced. I'm Xiomara pena. I am the vice president of community engagement and innovation at HOPE.

Briefly, Hispana's Organized for Political Equality is a nonprofit organization that has, for the last three decades, been focused on improving access to health care, on improving our education system, on increasing civic engagement across the state amongst Latinas, and around increasing economic mobility for Latinas as well.

So as you can imagine, under our health care work, this this has manifested our investment into also supporting research projects that also help define the challenges and solutions for us to build a more robust system that can serve families and women. And so in order to understand all of these inequities, we partnered with Black Women Organized for Political Action, the WAPA, to develop this this research of the twenty twenty five California equity and maternal health report.

This report looked at two focus groups and a public I'm sorry. Two focus groups and a public opinion poll.

The report captured the experiences of more than 800 black women and Latinas across the state, providing critical insight into the barriers they face in accessing safe, respectful, and high quality maternal health care through pregnancy, childbirth, and the postpartum period. Today, I'll highlight some key findings related to the experiences of Latinas and black women and discuss the opportunities to advance policies that improve maternal health outcomes for all communities across California. Next slide, please.

So while California has made important investments in maternal health, significant disparities remain, particularly for black women and Latinas. The United States continues to have one of the highest maternal mortality rates among high income countries.

According to the Centers for Disease Control and Prevention, the maternal mortality rate was seventeen point nine deaths per 100,000 live births in 2024. Black women and Latinas also experience higher rates of postpartum depression and pregnancy related complications, including hypertension, Preeclampsia, and preterm birth. These disparities are compounded by workforce shortages. Latinas make up only ten to twelve percent of midwives in California, while black women account for just two to four percent.

So we're talking about something meaningful that other speakers have also referenced, which is that access to culturally responsive care.

That can be a huge barrier for someone to actually receive the services that they need from our traditional health care system. So when we're talking about improving maternal health care, it requires, you know, two it's twofold, both expanding access to care and strengthening maternal health workforce. Next slide, please. Our research also found that the decision to have children and the experiences of new mothers are heavily impacted by economic realities.

Social determinants of health, such as poverty, insurance coverage, the barriers to health care access, environmental risks, among others, are also disproportionately and materialistically impacting black women and Latinas.

Our study found that more than 0.75 of black women and Latinas reported that financial insecurity concerns about how pregnancy would affect their health would influence how they choose to have children. In our research, black and Latina mothers rank a variety of resources and supports that would have been helpful during their most recent pregnancy or birth. A clear majority believed that time off work in general, about 60% of 60% was necessary.

Another 60% cited paid family leave from work, increase increasing our our pay rates there and then the income that's generated from paid leave. Breastfeeding and lactation counseling and support, 58%.

Of folks definitely talked about having professionals that could support them through that process. And, again, we heard both in the focus groups and through the online polling the importance of having the cultural competency of providers on on that piece as well. They also cited counseling therapy or mental health care services in general, about fifty four fifty four percent, that would have been helpful during their most recent birth or pregnancy.

And so these were all recent this was through our qualitative research element, our focus groups, and all of the participants had recently delivered or were pregnant at the time. And so we're hearing across this we heard from leaders and women across the state of California.

And as you can see there in just, you know, last year as we're doing these focus groups, clearly, there are still significant opportunities to close gaps because all of these items are are things that we typically will have will say we have solutions in place for. Right? However, the women that we were part of our focus groups did share that they really needed more access to those services and resources.

And lastly, you know, addressing maternal health means looking beyond clinical care and just recognizing that the economic and social factors that influence outcomes are there. So even when women seek care, many still face barriers in accessing the services that they need.

Next slide, please. Access still remains a major challenge across maternal health care systems. Only one in four black women and Latinas report difficulty accessing OB GYN care, and nearly one in three struggle to access routine health care. Mental health clearly also emerged as a significant concern. More than half reported experiencing depression during pregnancy or postpartum, and forty three percent experienced anxiety.

Yet nearly half said that they either did not receive or do not remember receiving a mental health screening during prenatal or postpartum care. It's very important because, previous to this report, we launched a report around mental health access and California's services and mental health care system for both black women and Latinas as well. And we saw that mental health services continue to be incredibly important for our community.

And so for our maternal for us to be able to create a more stronger maternal health care system, that was also referenced, as you can see, as part of the feedback that we were receiving for from Californians. And nearly one in four nearly four in ten women said that they simply did not know where to find a doula or midwife services, and sixty eight percent said that their health care provider never never gave them information about these services.

This represents a missed opportunity when patients cannot benefit from services that they are never told about. Increasing awareness and integrating these supports into routine prenatal care could help improve both health outcomes and patient experiences. So access alone, however, is not enough. Latinas and birthing individuals must also feel respected, heard, and safe within our health care system. Next slide, please.

We know that trust is built through respectful and equitable care. More than half of black women and Latinas reported experiencing unfair or adverse treatment during pregnancy or childbirth. Equally concerning, fifty nine percent reported they do not know how to file a complaint if they experience discrimination. And when patients don't know their rights or how to report concerns, accountability becomes difficult. At the same time, respondents overwhelmingly recognize the importance of representation.

Nearly eight in ten black women and a majority of Latinas said increasing the number of black and Latina maternal health providers is extremely important. Building a diverse workforce not only improves representation, it helps strengthen trust between patients and providers. I wanna just touch on that point real briefly. Recognizing that feedback, just this year, we also released a health care, workforce report as well. Also trying to unpack, where we can see additional solutions.

So as you can see, these three reports over the last three years really built on one another. We started with our mental health care report and how black and Latina women are, experiencing with California's mental mental health, system and services and what resources we still need. Then we moved on to maternity care, and we wrapped up with workforce. We know that these systems are all integrated and important for us to have healthy Californians and for folks to feel well supported by the state.

Last next slide, please.

So some key recommendations about from our findings point to several opportunities for policymakers and health systems.

So starting off with centering the voices and lived experiences of women and birthing people in maternal health policy and program design, continuing to invest in a culturally responsive maternal health workforce by increasing opportunities for black women and Latinas to become physicians, nurses, midwives, and other maternal health professionals, expanding access to supportive services, including mental health care, lactation support, nutrition counseling, health care resources, and paid family leave, and ensuring health care providers consistently educate patients about available maternal health resources and their rights through pregnancy and postpartum care.

By addressing these priorities, California can continue leading efforts to improve maternal health while ensuring equitable outcomes for all communities. With that, next slide. I wanna thank again.

Thank you, Tara. Thank you for putting this together, and I'm happy to answer any questions. And you can access our full report on on our website as well as you can see through that link.

Thank you so much. I wanna start by just flagging something that you mentioned about, you know, access versus actual ability to access and the doula example you utilized in my own experience and and, you know, being empowered and knowledgeable to ask my provider how I could identify a doula when I gave birth to my baby recently. And they didn't know how to access a list. My my OB Wow.

Yeah.

Would talk to me about, you know, hearing that it was covered, thinking it's great, but not knowing herself

Where I could go to find that list. And so I think it just speaks to exactly what you said and to my own lived experience of just, you know I can only imagine for folks who who don't even know that it's covered, which was an amazing legislative win, but it's all about how it impacts the woman in in the room that, you know, our work really matters.

And if I can just thank you for sharing that. One of the it just reminded me of one of the focus group participants from our Latina focus group was out of the Inland Empire area of Riverside, and she shared, you know, again, look interest in in holist more holistic related services, doula services, and and other resources, and specifically share that it took her about two months to find a Latina doula. And it was incredibly challenging. She had to travel well outside of the county.

Are there other doulas available?

I there might be. But, essentially, she was sharing. She did not know where to go. You know, her health care providers weren't able to also direct her and provide that guidance. And so, you clearly, this is a an area where we can see some investments and to improve that system because, you know, we know that that is that is something that folks need.

Yeah. Yeah. And I think that comes back to one of the the the themes of the workforce and availability. You mentioned your workforce report, and I wondered which, if any, of the recommendations you felt might be shovel ready for legislation or what might take more long term investment.

Yeah. Well, I think the the report does highlight clear gaps in access to mental health care screenings, doula and midwife services, patient education, and provider training. So these are areas where policymakers can take meaningful action now by strengthening and guaranteeing the delivery of these existing programs, improving care coordination, and ensuring patients receive respectful, high quality care throughout pregnancy and postpartum.

When I think the other piece, increasing the number of black and Latina OB GYNs and nurses and other maternal health providers means strengthening our education and workforce pipelines, supporting recruitment and retention, and creating pathways into these professions over time. We found that when it came to some of the barriers, and these are things that you've probably heard, you know, folks lack some of the resources economically to be able to pursue, medical degrees.

We just we just heard how how 300 k investments could be expensive and could be a barrier for communities to be able to pursue that kind of career. And so, again, additional supports could be part of that solution. So by both approaches are essential to provide improving maternal health outcomes by addressing immediate barriers to care and investing in the long term solutions. California can strengthen the maternal health system and ensure that women and, families have access to safe, respectful, and high quality care.

Thank you. I think, investment is also a common theme and such a challenge in our current environment where we're, again, struggling to fill gaps that the Federal Government is creating. But it's so critical that, you know, each of the panels lifted that up as a priority so that we can assure we relay that in budget discussions and all of these stories and data points. It's incredibly helpful.

So I wanna just thank you so much for your presentation and for closing us out in the back to the lived experiences and the voices of those who are impacted by all these policies and programs and who we are able to support moving forward by hearing their stories

Yeah.

And finding solutions based in community. So thank you so much for that. Okay. I want to recognize that we have so many committees this morning, and I wanna thank our members who have been able to come in and may have had to step away and assure you that as we move right now for public comment, we're gonna relay anything, any of the information that they may have missed when they stepped out. And we really just value your time and for being here with us today.

So we're now gonna take public comment. I'd like to ask members of the public to please keep remarks to two minutes so that we can hear from everyone who would like to speak. Please provide your name, your organization, and your comments. Yes? Come on over.

Thank you. Good almost afternoon, madam Chair. My My name is Maria Lemos. I'm executive director of Vicente Compramiso and our network of promotoras y Trabodores Comitares across the state, representing thousands and thousands of leaders in our communities across 52 counties in California. And my comment is really about maternal health shapes, that it's really more than a single issue. I really appreciate the CBOs who presented earlier focusing on the community advocate. And what whether we call them a community advocate in one culture or the other, they are those moms, those grandmothers, and those helpers.

name is Maria Lemos. I'm executive director of Vicente Compramiso and our network of promotoras y Trabodores Comitares across the state, representing thousands and thousands of leaders in our communities across 52 counties in California. And my comment is really about maternal health shapes, that it's really more than a single issue. I really appreciate the CBOs who presented earlier focusing on the community advocate. And what whether we call them a community advocate in one culture or the other, they are those moms, those grandmothers, and those helpers.

We're here to support that while I'm listening to the technology piece and the DHCS and all the strategies, it's very it's overwhelming. When in the end, it is my mother and my grandmother who are gonna help my Tia and my cousin and my sister get through this get through connecting and get through finding the resources and even giving birth. I think that we have to continue to realize to to rely on community based organizations and promotoras in the community.

We're called different names in different communities, but not the community health worker who is with clinics, hospitals, and plans, but the the promotora who's there day to day. I think we not only do the navigation, we do the prevention.

We have programs that are out there for mothers and for the children. Has programs in caregiving from zero to five all the way to death and dying, caregiving for the older adults and those who are death and dying. So we know the community is the answer. What we're requesting and really asking for is while you're gonna focus on different strategies and philosophies and and systems that really the the the go to should be community and it should be promotoras across the board.

And so that's my my ask here.

You all can go to our website. You can see what we're doing as an organization. We're reaching millions. We reach literally millions of families and, in community every year, and we're one organization. So you can imagine how many of our hundreds of organizations we're reaching.

And so I'm asking for a focus on CBOs. I know the money is tight, but now more than ever, you need . And so that little bit that is invested in promotoras is gonna go a long way in these difficult times. Thank you.

I was gonna say good afternoon, but good morning, madam Chair. Natalie Pita on behalf of the California Academy of Family Physicians. I wanna thank you and your staff and today's speakers for this meaningful discussion. While California has made important progress expanding access to reproductive health care, significant disparities in maternal health outcomes persist. Improving these outcomes requires ensuring that patients have access to both comprehensive reproductive health services and longitudinal primary care.

Reproductive health care is essential for meeting patients' family planning, pregnancy, and reproductive health needs, while primary care provides ongoing preventative care, chronic disease management, behavioral health support, and continuity before, during, and after our reproductive years. Through a whole person approach and long term relationships with their patients, family physicians are uniquely positioned to identify and help address the social determinants of health that contribute to these inequities. We urge

the legislator to continue investing in the primary care workforce, increase access to reproductive health care, and social services so that every Californian can receive coordinated equitable care. Thank you.

Hello. Sarah Diaz with the California WIC Association. Thank you Assemblywoman Rodriguez for your leadership this year and in recent years, in advancing reproductive and maternal health equity in California. Your commitment to addressing long standing disparities has helped move this critical conversation forward. And, obviously, from our panelists, like, this is such a broad space with so many areas of, improvement and so much work to be done.

But, as we look ahead, we see important opportunities to build on progress that's been made in the lactation area, especially since we are right in the middle of WIC breastfeeding week, national WIC breastfeeding week, national breastfeeding month, and world breastfeeding week. So some some opportunities would include improving data collection on lactation provider demographics and geographic density, as well as breastfeeding initiation and duration rates to better identify gaps and access and outcomes.

As you know, as the author of AB 2160, we also encourage initiatives to allow lactation support providers to be eligible to enroll as independent medical providers, ensuring families can access timely culturally responsive care. And finally, we urge we urge continued attention to the quality and standards of breast pumps provided through Medi Cal along with reimbursement rates that support access to high quality equipment that allow families to better meet their lactation goals.

These steps would help ensure that all families, particularly those who experience the greatest inequities, have the support they need to achieve their infant feeding goals and improve maternal and infant health outcomes.

So thank you for your continued leadership and partnership.

Thanks, Christine Smith, Health Access California. Super appreciate this opportunity and your leadership on this issue. We are also in support of AB 2160. We are proud to be a cochair of the

Health Fraud Campaign along with the California immigrant policy center. In the last decade and more, California has made historic progress toward removing barriers to health care for all regardless of immigration status. And and today, roughly 1,600,000 undocumented Californians rely on medical for their health care including the many benefits that were included in this hearing. However, this progress is now at risk following the state budget cuts to medical for adult immigrants in the last two years.

These devastating cuts will prevent access to essential health care and create separate and unequal systems of care.

And while these cuts don't largely apply to pregnant people, they certainly apply to the people that are supporting them, which is just so important. No premiums are acceptable. Too many Californians will lose health care and be forced into impossible choices. They will go to the ER for basic care or die younger from preventable illnesses. The medical freeze needs to end is shifting care to counties, hospitals, and emergency departments while decreasing stable stability for families that need it.

Now more than ever, we must fully restore this program to serve all Californians and include our state's commitment to health equity and universal coverage. Thank you.

Good morning, madam Chair. Karen Stout here, on behalf of the California Nurse Midwives Association. We just wanted to thank you and the committee for convening this critical hearing, and particularly to CDPH and our partners on the panels for highlighting this important issue. We were also really happy to see a continued focus on midwifery care as an important element in our state's broader maternal health strategy, as well as focus on education pathways, which I'll go a little bit into later.

As reproductive health care providers and as an association, we remain deeply concerned about health inequities in communities of color, particularly disparities that persist in maternal mortality rates across California.

Midwives play a critical role in advancing health equity alongside the full spectrum of maternal health providers, particularly in perinatal and reproductive health. As is a surprise to no one here, black and indigenous birthing people in California experienced significantly higher rates of maternal morbidity and mortality, and for free care has been shown to reduce interventions such as cesarean birth, preterm birth, and low birth weight, outcomes that disproportionately affect those communities.

Currently, certified nurse midwives, RNs who go back to school for a Master's or a deep or a, MBA level education, currently attend fourteen percent of births in California and often fill the gap in OB GYN and other provider deserts. By increasing access to midwives and continuing to include the midwifery model of care in the state's approach, we can support a system that improves clinical outcomes where disparities are most pronounced.

In particular, in response to the education pathways, which we've already, outlined some really productive solutions today, which I'm excited to take back.

I also wanted to flag a chart some targeted bills and investments we've established over the past couple of years to establish education programs for CNMs. Our bills last year, AB 836 by Assemblyman Marceffani and SB 520 by Senator Caballero, provide both short and long term solutions. While we were very grateful to see funding for AB 836, our landscape analysis to discuss how midwifery can be expanded to develop more robust and financially sustainable education pathways.

SB 520, our work with Senator Caballero has not yet been funded. This bill would require 2,000,000 to establish a second master's level program here in the state of California.

Currently, we only have one To create more culturally competent CNMs, particularly in underserved areas, to increase the supply of providers that are providing this care, and also to to provide a more financially viable pathway, particularly as we're seeing cuts to federal loan structures up there at the national level. Thank you for creating this space for discussion. We look forward to working with you and other members of the committee on this key policy area. Thank you.

And then if it's alright, I'd like to give a brief comment on behalf of my other client, Unidos US.

We just wanted to echo the other presenters in thanking the committee for convening this hearing to continue to examine structural disparities that disproportionately affect Latine communities and their birthing people of color. As other panel as other commenters have mentioned, we are grateful to hear this particularly as sweeping health care cuts to Medicaid and Medi Cal continue to impact those communities, and we are due to continue to examine, improve, and fund those health care systems to remove in barrier those barriers and engage in more systemic growth.

Thank you.

Good afternoon. My name is Anna Alvarez, and I'm with the Health for All Coalition. We're a coalition of over a 150 organizations across the state united in ensuring every Californian can access Medi Cal regardless of immigration status. State and federal cuts to immigrant health access are contributing to a lot of uncertainty and instability for immigrant women and their families. Since June 2025, nearly a quarter million undocumented immigrants have fallen off of Medi Cal.

This is a quarter of a million people in the last year alone, and many of the health care cuts have not even been implemented yet. A quarter of a million people that are now locked out of medical because of their current enrollment freeze for undocumented Californians. As more cuts start to be implemented, we expect the number of immigrants dropping off of medical to continue to plummet. The state must do everything they can to ensure medical doesn't close their doors on anyone no matter their immigration status.

This ensures access to preventative and primary care including reproductive care and maternity care.

Thank you.

I am a citizen of the Iron Band of Miwok Indians. I am a basket weaving student under the tutelage of Jennifer Bates. I'm also a licensed marriage and family therapist here in Sacramento, working with clients from queer community, two spirit community, and other indigenous communities for the past thirteen years. I'm also a PhD candidate and a founder of a local nonprofit Advocacy Rooted. We're an organization dedicated to indigenous led healing, cultural education, and land stewardship.

I wanna start with something I hold close. Indigenous healing practices have been sustaining our communities since time immemorial. They are not alternatives to Western medicine. They are medicine, period. They carry the knowledge and resilience of our ancestors.

And right now in this sociopolitical climate, funding for community based programs like these is not just helpful, it's essential. I'm grateful this committee is examining reproductive and maternal health disparities. One thing that stayed with me from today's presentations is the distinction between culturally responsive excuse me. Culturally responsive and culturally grounded programming. We do not need health care that simply acknowledges us.

We need health care that is built with us from the ground up. Let me share an example. Basket weaving circles, for example. At every stage, plant identification, gathering and cleaning materials, weaving with elders and children in safe community spaces. This is generational learning and story tell storytelling woven in.

These are the healing spaces. They build trust and solidarity across communities, reminding us that our struggles and healing are not separate. We also have, to hold space for the weight of our history, Genocide, enslavement, ongoing structural racism, and reproductive oppression. These were hard presentations to sit through today as a clinician. These are not abstract concepts.

They're lived realities that shape our health outcomes today. One more thing I wanna name very clearly, I promise I'll wrap up shortly. Indigenous people are also black. They're also Latina. We have two spirit relatives whose identities and experiences deserve to be seen and heard.

Our identities overlap, and any real effort to close gaps in care must honor that. Thank you so much for your time today.

Hello, everyone. My name is Anaie Matias Santiago, and I'm a fellow with the California Latino Capital Association Foundation. And I just really appreciate all the work that multiple organizations have done to lead the health care health care advocacy and policy through the lens of equity and community based practices. Coming from a very intersectional background, I think these approaches are the best to, like, actually address, like, language barriers, immigration status, race, socioeconomic status, and just different backgrounds and ethnicity.

I myself, I come from a Latina background, but also my family is indigenous migrants, from Oaxaca, Mexico.

And so navigating health care has, like, consisted of navigating between, like, multiple languages. So whenever we go into the hospital, it's translating not only from English to Spanish, but from English to Spanish to Zapoteco. And so that kinda makes, like, an I think sometimes a slower process when identifying health care for my family. And so I really, really resonated with the folks from the Planned Parenthood affiliates of California that highlighted this very lived experience.

And I just wanna thank the Chair for this space for dialogue and the team who helped, like, organize it.

Yeah. Thank you.

Good morning, Madam Chair and critical staff that helped made this committee possible. Thank you so much for the opportunity to hear from our community partners today and the ability just to learn more about what Latinas are facing across the state and our indigenous community as well, black women, and the intersectionality that we all share in different spaces and times. As a queer Latina and a lot of my friends and colleagues who go through that maternal space.

I know they've shared their own experiences and just the ability to have more inclusive language and supporting mothers who might, be to parents going into these spaces and being able to make space for them as well is something that I've heard from my own friends and family. And as I look towards that one day with my own partner, I hope that, you know, the the health space is more inclusive when when we get there as well.

And, today, I just wanted to really encourage the legislature to really take some of the recommendations that community partners elevated. I know that they couldn't be here today. There was a lot of committees happening simultaneously and all, but, really, it sounds like there's an ability to really look at policies that might be sunsetting that could be a quick fix that the legislature could really look into, as well as looking at other policies that may have been, passed but haven't been funded.

And then maybe looking at what are those bridges that are still missing for us to really bring attention to some of those pieces, whether it's just education or informing our community members. All that to say, thank you so much for the opportunity to have this space.

Thank you.

Hello. My name is Aston Georgiel Williams. I am here with the California LGBTQ Health and Human Services Network. Thank you all so much for having this conversation. It's needed.

I wanna echo what I didn't catch your name, but what were my yes.

What my friend said, about inclusivity. I just wanna say that I think it is really important for us to center LGBTQ communities of color, as Sky had said as well. That means that they're not only women or mothers that are having children, they're also individuals who are to identify as just birthers, or have other gender identities. And I

think that's something that we really do need to take into account when we are doing this work is that, if we're intending to be intersectional, that includes all people who are birthing people. And so I hope that that continues through the work that is done, with the legislation that's coming up and also just moving forward that we do mean what we say when we say inclusivity and intentionality. So I appreciate the time. Thank you.

Hi. I think it might be afternoon now. Yes. Good afternoon. I just want to highlight two points.

One that you made, Chair, about, the sunsetting of youth teen pregnancy prevention, and I just wanna highlight that for a lot of Latinas and and young, black youth, teen pregnancy prevention has been a big reason why we've been able to make economic mobility strides.

And so the fact that programs are sunsetting, I think it's a big cause for concern and something certainly we should be looking at because it's gonna have impacts not just in economic mobility, educational attainment, but also in maternal health as we're looking at that population potentially getting younger. And there's also a role for government to play separately on the workforce, a piece for the health care workforce. Riverside County is doing some interesting stuff with the support of the economic workforce development department.

They're looking at youth youth development workforce training in the health care space that might be very interesting to model in other counties.

The University of UC Riverside also has programs to support kind of community specific free medical care that maybe is something we can use at other UC medical institutions, and so I just wanted to highlight those. I'm not from that community, but it's it's something I've been following, and it's very interesting. I am Diana Maya, vice president of programs at Hope. I work with young people. When our programs first started, we looked at teen pregnancy prevention as a big issue for us as an organization.

As Latinas have made progress in that space, we have focused our work on mental health young people. And so that really, for me, that comment you made about this sunsetting programming raised a really big red flag for me as something we don't we wanna make sure we're moving forward, not backwards. Thank you.

Hello. It's me again. But provide I didn't wanna take up some of my time sharing our research, but I wanted to ask Jimara Pena. Wanted to share very briefly, a personal comment as well. So I was a teen mom myself, benefited from the adolescent youth, life planning's, program, a volunteer program once my school connected me to that resource.

Also, you know, was on Medi Cal during my teen pregnancy, and I can share with you that that experience was extremely challenging in terms of comparing it to my second born son with under my private health insurance with Kaiser and feeling well supported through that, through that whole process. When, I found out I was pregnant, I was also, I also went to a crisis pregnancy center, unbeknownst to myself.

And, unfortunately, they used delaying tactics, and so I was unable to actually make a well informed decision around what reproductive options were available to me at that time. So if the state could also do some more work around ensuring that our community is aware of what these predatory centers do, that is something that we need to continue to look at as well.

Again, during my teen pregnancy experience, that was extremely challenging with Medi Cal having to take full days off of school in order to sit in long waiting rooms in order to be seen for my regular checkups.

That was my experience. Okay. Then transitioning, you know, I've gone to school. Now I have a career. Now I have a job.

Great. Have great private health insurance. That experience was completely different. That experience was a well informed provider network that was able to provide me with all the information I needed during my pregnancy. It felt very supported.

And so, again, there are improvements that continue to need to be made. I was also able to serve on California on our California Paid Family Leave Task Force that Governor Newsom put together back in 2019. I was one of the few people that actually had benefited from California's paid family leave system only. That was one of the 10 leaders across the state selected to make those recommendations to legislature, many of which have thankfully, been acted upon. So I just wanna thank you, for your leadership.

Again, the state continues to do great work. As my colleague Diana mentioned, it's important for us to continue these services. I'm a product of these investments, and I just wanna acknowledge and thank you. And thank you for giving some space to shed.

Thank you so much. I wanna thank everyone who provided public comment. I think it goes with the theme of just centering the voices of those who, experienced this, all birthing people who have experienced different barriers, and really just close this out today with recognizing how we started.

You know, the fact that we've been we have this history that we're building upon of terrible things that have happened, but also the fact that we're having a select committee on Latina inequities in the California state capital to talk about reducing disparities just shows how much progress we've made. And to take some of the words from one of the folks who made public comment, we wanna make sure we continue to move forward and not backward.

And so it was I'm just so grateful to everyone who presented today, all of our presenters who showcased, the progress that we're making, the programs underway, the policies that we need, and the gaps that we still need to close. Because the fact is who you are and where you come from does decide what your outcome is, and that's unacceptable.

And so I just wanna, you know, reinforce my thanks to to our committee members who are able to join us, assure you that we'll follow-up with all of the recommendations you provided and all of the ideas and all of the things that came up for a really important follow-up. And we're gonna continue to look at the gaps through this committee, how we can resolve them through legislation and partnerships and funding is such a critical component.

We have community based solutions, and we need to continue to lift them up.

And while we look at the data, we have to look at the stories, and all of it comes full circle so we can keep making progress. So thank you all for all of the work that you do and all of you for staying today and providing your public comment. We're so grateful. Please stay involved. We'll continue to do the work with you.

And with that, this hearing is adjourned.