Recommendations were common; follow-through was harder to measure
All 10 selected maternal mortality review committee reports examined by GAO included recommendations on care coordination. Nine included mental-health or substance-use recommendations, and nine included health-equity recommendations.
But nine of the 10 committees told GAO that tracking implementation was difficult. The committees review deaths and recommend changes; they generally do not control the hospitals, agencies or lawmakers responsible for carrying them out.
| Measure | Selected committees | Share |
|---|---|---|
| Reports with care-coordination recommendations | 10 of 10 | 100% |
| Reports with mental-health/substance-use recommendations | 9 of 10 | 90% |
| Reports with health-equity recommendations | 9 of 10 | 90% |
| Committees reporting implementation-tracking difficulty | 9 of 10 | 90% |
Federal support expanded, but four measures lacked targets
CDC planned about $134 million for 52 recipients during the 2024–29 cooperative-agreement cycle, up from about $65 million for 46 recipients in 2019–24. The expansion supports review committees and related maternal-health work.
GAO found CDC had 15 performance measures. Eleven had targets; four newer measures did not. Without targets, data can describe activity but provide a weaker basis for deciding whether the expanded investment is producing expected progress.
The gap sits between recommendation and accountable result
The original finding is a governance mismatch: committees repeatedly identify similar preventable-system problems, yet most selected committees lack an easy way to verify adoption and impact. Publication of recommendations is therefore not the same as implementation.
GAO did not say the recommendations were ignored. Tracking can be difficult even when hospitals or states act, and some changes take years. The report supports a measurement gap, not a claim that nine committees failed to improve care.
Method and limitations
The newsroom reviewed GAO’s report, separated report-content counts from committee interview responses and calculated the displayed shares. GAO examined committee reports issued from 2021 through 2025 covering deaths from 2014 through 2023.
The 10 committees were selected for the review and are not a statistically representative sample of every jurisdiction. Their answers should not be generalized into a national implementation rate.