Oakland’s public conversation about health care must begin with a simple truth: a doctor’s appointment is not the same thing as access to care.

For a mother juggling work and child care, access may mean a text-message reminder, a bus pass, an evening appointment, or someone who can explain what Medi-Cal covers. For an older patient managing diabetes, it may mean help scheduling a specialist visit and understanding new medications. For a family that has been dismissed or misunderstood in medical settings, access may begin with meeting a community health worker who knows the neighborhood, speaks their language, and treats their concerns with respect.

Community health clinics make that kind of care possible. They are part medical provider, part navigator, part educator, and part trusted local institution. Proposition 44 threatens to narrow the definition of what counts as patient care in a way that could undermine the very supports that allow patients to receive it.

The statewide measure would require covered nonprofit community clinics to spend at least 90 percent of their annual revenue on health care or qualifying program services. The ballot measure directs the Attorney General to establish more detailed guidance on what expenses qualify. Clinics that do not meet the threshold could face penalties for the difference. The Legislative Analyst’s Office reports that affected clinics currently spend an average of about 80 percent of revenue on health care services.

A percentage may look like a clean measure of accountability. But health care is not cleanly divided between what happens inside an examination room and everything that enables a patient to enter one.

Consider the work that happens before and after a visit. Clinic staff maintain confidential patient records. They follow up after missed appointments. They keep information systems secure. They recruit and train employees in an expensive and competitive health care labor market. They coordinate referrals, process claims, purchase supplies, maintain buildings, and make certain that patients are not lost somewhere between diagnosis and treatment.

Oakland families should not be asked to accept the fiction that these functions are unrelated to care.

The danger in Proposition 44 is not only its 90 percent figure. It is that the meaning of “qualifying” spending will be worked out later. A clinic preparing a budget today may not know whether a navigator, health educator, transportation program, outreach worker, technology upgrade, or other patient-support service will be counted the way it expects. Yet the financial consequence of getting it wrong could be immediate.

The Legislative Analyst’s Office says clinics falling short of the requirement could be required to pay the shortfall amount to the state and could seek to recover the money only if they show compliance within five years. The same analysis estimates state enforcement costs in the low tens of millions of dollars annually, supported by fees.

That is a troubling arrangement for organizations that are expected to provide care to people with the fewest alternatives.

Oakland has learned that trust is not built through slogans. It is built when a patient is listened to, when a parent can secure an appointment for a child, when a clinic returns a call, and when a person receives help without being shamed for their income, insurance, language, immigration history, or prior experience with the system.

For Black residents in particular, trustworthy care is not an abstract goal. Persistent inequities in health outcomes and patient treatment are real. Community-centered clinics can help bridge the gap with culturally responsive staff, patient navigators, behavioral-health programs, and partnerships that understand the conditions shaping health outside the clinic door.

Proposition 44 could pressure providers to treat those supports as expendable because they do not fit neatly into a state-enforced formula. That would be a mistake.

Accountability is necessary. Clinics that receive public resources should be transparent, well governed, and focused on their mission. But good oversight asks whether patients are being served well, whether money is managed responsibly, and whether communities can obtain needed care. It should not rely on a rigid ratio that may punish clinics for doing the hard work of reaching people who need more than a brief medical encounter.

A broad coalition of providers and community organizations opposes Proposition 44, including the California Primary Care Association, the California Medical Association, the California Hospital Association, Planned Parenthood Affiliates of California, and the California Teachers Association.

Oakland needs health policy that expands the circle of care. Proposition 44 risks drawing that circle smaller.

The Oakland Post editorial board urges a No vote on Proposition 44.

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By Antoinette Stewart-Eneh, Special to California Black Media Partners

Word Count: 1058

Note: Client A, B & C, names are withheld for privacy; these accounts reflect my recollections as their Doula.

Client A rocked her hips on a birthing ball, surrounded by pale wood and warm textiles in a softly lit Scandinavian-style office. I was her doula through a Southern California maternal health company combining nurse-led care, technology, and wraparound support.

She was a healthy Black woman in her thirties. Her baby girl was doing well; her partner took notes as we discussed labor and advocacy.

Then we turned to their chosen hospital. I knew it well—and remembered a phrase from another client’s experience: “Policy of Sovereignty.”

Client B had been told she needed a repeat cesarean as a precaution, though the reasoning was unclear. Her obstetrician, who performed her first cesarean two years earlier, had assured her throughout pregnancy that she was healthy, healed, and ready for a vaginal birth. We asked staff to review her chart, consult her obstetrician, and reconsider immediate surgery. Instead, they invoked the “Policy of Sovereignty.”

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The physician on duty, we were told, had final authority, regardless of her established care plan. I asked whether an ultrasound or reassessing the baby’s position could offer clarity. Cesareans can be lifesaving. But were Client B’s history, informed consent, and circumstances guiding this decision—or was routine overriding individualized care? We kept asking for her obstetrician. Beneath every request was a deeper question: Was she being heard?

The Numbers Behind the Stories

Statistics arrive in clean columns. The experiences behind them do not.

Maternal mortality and pregnancy-related mortality use different time frames and methods and are not interchangeable. Finalized 2024 CDC data recorded 649 maternal deaths nationally. The overall rate was 17.9 deaths per 100,000 live births, but for non-Hispanic Black women it was 44.8, compared with 14.2 for White women and 12.1 for Hispanic women.

In California, Black birthing people experienced 56.5 pregnancy-related deaths per 100,000 live births during 2020–2022—3.8 times the White rate and four times the Asian rate.

As a doula serving Los Angeles and San Bernardino Counties, I see faces behind those numbers. I remember concerns raised softly, then firmly, then desperately. I am tired of watching Black families enter spaces meant to protect them, only to discover they must defend themselves while laboring, bleeding, trembling, or recovering.

Returning to Client A

Client A’s labor stretched nearly 48 hours. As her condition worsened, she, her partner, and I asked whether a cesarean should happen sooner. A provider questioned my place as a doula, then said she was next.

Six more hours passed.

She entered surgery visibly ill with a serious uterine infection, her baby malpositioned and stuck. Her partner later recalled the provider saying, “This baby would never have made it through the birth canal.”

Those words landed like a blow. Our urgency had been treated as ignorance. With Client B, we questioned why surgery was inevitable. With Client A, why it was delayed. Doula advocacy is not about one kind of birth. It is about informed consent, individualized care, and timely action. Hospital routine should never outweigh the person carrying the risk.

Survival Cannot Be the Standard

The Black maternal health crisis includes unequal care, untreated conditions, racial bias, delayed referrals, poor communication, and inadequate postpartum support. It is about birth plans respected only until a hospital becomes less busy and postpartum care that asks whether a mother survived, not whether she has what she needs to recover.

Survival cannot be the standard. Technology can support care, but it cannot replace human connection. An algorithm cannot detect fear in a patient’s eyes, and a mission statement alone cannot ensure adequate staffing or culturally responsive care.

The Story of Client C

Before I arrived, I heard the chaos through Client C’s phone. Staff struggled to locate her baby’s heartbeat on an external monitor as her fear and blood pressure rose. I pleaded for an internal electrode before surgery.

“There’s not enough time,” a nurse said.

“I would like to wait for my doula,” Client C called out.

But she was medicated, hurried through consent, and wheeled away while I listened.

In the operating room, after a shift change, another nurse placed an internal electrode and said, “The previous monitor wasn’t working.”

No one responded.

According to her father, the obstetrician avoided eye contact: “We need to move forward.”

Surgery may still have been necessary; that was not mine to determine. But if faulty equipment helped create the emergency, the family deserved acknowledgment and explanation—not silence. No family should have to wonder whether major surgery followed an unavoidable crisis or a machine failure no one recognized in time.

From Prevention to Accountability

After supporting nearly 100 families, I have learned that danger often begins before admission. I have urged clients to seek care—and heard why they feared returning: dismissed pain, harsh words, shame for asking questions.

Care cannot be holistic where Black families do not feel safe enough to speak or return. Representation matters, but providers of color cannot repair inequity alone. They need adequate staffing, mentorship, culturally responsive training, reliable equipment, and colleagues that are reflective of all the aforementioned. It’s not the Black providers job to care for just the Black patients, everyone should have the same goal.

The Momnibus Act, California’s Medi-Cal doula benefit, the Transforming Maternal Health Model and the Perinatal Equity Initiative require more than promises; they need sustained funding, reliable reimbursement and accountable implementation.

Birth should be sacred. Yet too many Black birthing people arrive carrying the burden of proving their pain is real. A doula can listen, educate, comfort, and advocate—but cannot repair a system that refuses to listen. The true measure of progress is what happens when a Black birthing person says, “Something is wrong.”

Are they believed? When equipment fails, is that failure acknowledged? Do families leave not merely alive, but safe, respected, supported, and whole?

Until those answers are consistently yes, California’s maternal health success story remains unfinished.

About the Author

Antoinette Stewart-Eneh is a mother of two, holistic maternal wellness advocate, and birth and postpartum doula who has supported families since 2019. She serves as program operations coordinator for Frontline Doulas, a volunteer client coordinator with the Joy in Birthing Foundation and a childbirth educator in South Los Angeles. She is studying to become a midwife and lactation educator.

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By McKenzie Jackson, California Black Media

After losing twins, Long Beach resident Cassandra Carter approached the birth of her daughter, Nyomi, last November with anxiety. She wanted support for herself and her husband, Adewole, that extended beyond routine medical care. 

“Getting pregnant as a Black woman, I wanted a team around me that made me feel safe,” she said. “I know all about the mishaps that Black women experience.”  

Carter, a therapist and self-described hippie, hired Yvette Perry, a doula and co-founder of Divine Birthing Services LLC in Lancaster. Perry helped Cassandra craft a detailed birth plan. 

“I was worried about postpartum depression. Mrs. Yvette knows a lot about how postpartum affects men as well,” Carter explained. 

Perry was present the day Nyomi was born. She held the baby when Carter or her husband needed a moment and even set up candles in the birthing suite.  

“Whatever I needed for my comfort, she was there,” Carter said of Perry. “She was there as an advocate and voice. I had a really serene birthing experience because I had someone extra who wasn’t tied to me as my family.”  

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Perry, a doula for nearly six years, said preexisting conditions, poor communication and dismissive hospital care heighten health risks for Black mothers. 

“Sometimes, Black mommies are not being heard. They don’t know they have rights. They don’t know they can say, ‘no,’” Perry explained. “Doulas empower them. We are there to educate them.” 

Perry’s concerns reflect a broader public health crisis. According to the Centers for Disease Control and Prevention’s 2024 maternal mortality report, non-Hispanic Black women in the U.S. died from pregnancy-related causes at a rate of 44.8 deaths per 100,000 live births. 

In California, Black women experience the highest pregnancy-related mortality rate — about four times greater than other women, according to statistics. From 2021 to 2023, the leading causes of pregnancy-related deaths included cardiovascular disease, COVID-19, hemorrhage, sepsis, amniotic fluid embolism, and pulmonary embolism. 

The Centering Black Mothers in California report found that structural racism — including barriers to high-quality health care, and chronic stress— disproportionately harms Black women. 

In a statement to California Black Media (CBM), the California Department of Public Health (CDPH) said maternal mortality disparities stem from multiple factors. The department said addressing structural racism, listening to Black women’s experiences and reducing provider bias are key to closing the gap. 

California began covering doula care as a Medi-Cal benefit in 2023, providing eligible patients with support during pregnancy, childbirth and the postpartum period, according to CDPH.  

Whitney Dotson of Inglewood wanted an expert on pregnancy, labor, and delivery to guide her and her husband, Anthony, through the birth of their son, Anthony III. So, she hired Perry for doula support. 

“It’s always more comfortable when you can have a second opinion,” she said. “Knowing she was better versed in what the options were, made me more comfortable.” 

Dotson, 39, had a healthy pregnancy but faced recommendations common for expectant mothers over 35. Her doctor advised inducing labor at 39 weeks, but she hoped to carry to full term. 

“I wasn’t comfortable with that,” she admitted. 

Perry provided Dotson with information about induction guidelines and alternatives, helping her understand her options and communicate her preferences.  

Then, Dotson returned to her doctor. 

“I said, ‘I don’t want to — and this is why,’” she recalled. “He agreed and pushed the induction date back a week.” 

Perry also advised Anthony on how he could support his wife during and after the pregnancy and during Anthony III’s birth. She also reminded Dotson to change birthing positions — from her back to her hands and knees.  

Before Saveneh Martinez became a doula with Fierce Advocates in Contra Costa County, she was a new mom, uneducated on aspects of birth, which led to her first child, Colton, being placed in a Neonatal Intensive Care Unit. 

“I didn’t know my choices,” she said.   

Martinez called it “lifesaving” for expecting moms to have a doula.  

“It should be a medical right,” she said.  

California Perinatal Quality Care Collaborative (CPQCC) Senior Associate Medical Director Kimberly D. Gregory said research suggests that doulas decrease the pre-term birth rate and the likelihood of a C-section.  

“Having a doula is a proactive thing to do,” she said.  

Efforts are being made across the state to reduce maternal deaths.  

CDPH’s Title V Action Plan aims to reduce pregnancy-related deaths among Black birthing mothers from 49.7 to 42.3 per 100,000 live births by 2030 through improvements in patient-centered care, expanding community-based perinatal teams, and addressing the social factors that contribute to poor maternal health outcomes. 

CDPH’s Black Infant Health (BIH) Program and Perinatal Equity Initiative (PEI) have already begun to make headway.  

“BIH’s prenatal group model improves key intermediate outcomes for participants, including increased social support and empowerment, better stress management, reduced depressive symptoms and gains in health knowledge and behaviors such as safe sleep practices and reduced smoking,” the CDPH told CBM.  

“PEI’s early implementation results show progress across several participant-reported areas, such as improved birth experiences, breastfeeding initiation, and coparenting skills among fathers and partners,” the CDPH statement continued.  

Gregory said the California Pregnancy Associated Review Committee examines maternal deaths and develops guidelines to help hospitals improve care. One of its main recommendations focuses on how hospitals respond to hemorrhaging, a leading cause of pregnancy-related deaths. 

Gregory said CMQCC also created standard clinic care practices for cardiovascular disease and sepsis, two more drivers of maternal mortality, but widespread implementation across the state is pending.  

She noted that although there are 800 maternal deaths a year in the U.S., there are also 3.6 million births.  

“Most people will do well,” she said. “But you should know about complications like preterm birth. You should know about complications like diabetes, preeclampsia and postpartum depression.” 

Martinez said doulas help to make birthing the transformative experience that it is, instead of a routine clinical transaction. 

“Being able to feel heard, seen, safe, respected, and just being able to create spaces for them to be held as well,” she said.  

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

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