Maternal Health: Information on and Federal Oversight of Mortality Review Committees

What GAO Found

The U.S. faces a maternal mortality crisis, with mortality rates that exceed every other high-income country. More than 600 women die during pregnancy or from causes aggravated by pregnancy each year in the U.S.; over 80 percent of these deaths are preventable, according to the Centers for Disease Control and Prevention (CDC). To help prevent these kinds of deaths, CDC provides funding for Maternal Mortality Review Committees (MMRCs). These committees, typically supported and maintained by state and local health agencies, identify factors contributing to pregnancy-related deaths and make recommendations to patients and their families, providers, hospitals, or state policymakers to help prevent similar deaths. They convene at the state or local level and comprise clinical and non-clinical representatives.

GAO found all 10 selected MMRCs consider federal and state laws and policies as potential factors that affect maternal mortality. For example, representatives GAO interviewed from five MMRCs said their states changed state laws to extend Medicaid coverage for certain women to 12 months postpartum, due to MMRC recommendations. Such health care coverage could save lives by treating and reducing chronic disease, such as severe hypertension, that can underlie maternal mortality, according to these representatives.

GAO found the 10 selected MMRCs commonly made recommendations in the areas of care coordination, mental health and substance use, health equity, reproductive health, and health care workers. For example:

• Mental health and substance use. Unintentional drug overdose and suicide were among the leading causes of death among pregnant and postpartum women, according to a recent study. Nine of the selected MMRCs made recommendations in this area, including for screening and referrals for treatment, and to increase funding for access to care.
• Health equity. There are persistent racial and ethnic disparities in deaths of pregnant women, with both Black and American Indian/Alaska Native women experiencing deaths at a rate of 2.5 or more times higher than White women, according to GAO’s previous work and CDC. Nine of the selected MMRCs made recommendations to address these disparities. For example, one MMRC recommended ensuring American Indian/Alaska Native representation in the planning and implementation of improvements in maternity care.

Over the 5-year funding cycle from 2024 through 2029, CDC plans to provide about $134 million to 52 states and territories. To monitor MMRCs that receive this CDC funding, the agency holds regular meetings, reviews required reports, and conducts site visits. GAO found that to assess MMRC performance, CDC has incorporated key performance management practices identified in prior GAO work. For example, CDC set a goal of eliminating preventable deaths and collects information on the number of MMRC recommendations being implemented.

Why GAO Did This Study

GAO was asked to provide information on MMRCs and federal oversight of them. This report provides information on whether MMRCs consider laws and policies when reviewing factors that contribute to maternal mortality, recommendations by MMRCs to reduce mortality, and CDC’s efforts to evaluate the MMRCs.

GAO reviewed the most recently available MMRC reports as of December 2025 and interviewed officials representing a nongeneralizable sample of 10 MMRCs, selected to obtain a mix of geographic locations and rate of maternal mortality, among other characteristics. GAO also reviewed CDC documentation and interviewed CDC officials. Additionally, GAO assessed the extent to which CDC is following key performance management practices.

For more information, contact Mary Denigan-Macauley at DeniganMacauleyM@gao.gov.