Army Corps of Engineers: Consideration of Project Costs and Benefits in Using Natural Coastal Infrastructure and Associated Challenges

The Corps constructs water resources projects to reduce risks to coastal communities from storm damage, among other things. These projects can involve building hard structures, such as seawalls, to protect against flooding and wave damage. The Corps and some state and local agencies are increasingly considering using natural infrastructure, such as wetlands, to reduce risks from coastal storms and flooding.

GAO was asked to review the uses, costs, and benefits of natural coastal infrastructure for the Corps' coastal storm and flood risk management projects. This report describes (1) how the Corps considered costs and benefits for selected projects that used natural infrastructure and (2) challenges the Corps faces in developing cost and benefit information for using natural infrastructure and steps taken to address them.

GAO reviewed Corps guidance; obtained information on projects that used natural infrastructure and received funding from fiscal years 2012 through 2017; randomly selected eight coastal storm and flood risk reduction projects from the Atlantic, Gulf, and Pacific coasts; and reviewed each project's planning documentation and economic analyses. Findings from these projects are not generalizable to all Corps' projects. GAO also reviewed economic literature, reviewed Corps documents related to the use of natural infrastructure, and interviewed Corps officials and stakeholders with experience in using natural infrastructure.

The U.S. Army Corps of Engineers (Corps) typically identified project costs and damage reduction benefits for the eight projects using natural infrastructure that GAO reviewed. In selecting projects, the Corps is to conduct economic analyses of project alternatives, which may include hard structures, natural infrastructure, or a combination, to compare their costs and benefits. Corps guidance states that for coastal storm and flood risk management projects it is to select the alternative determined to have the maximum net benefits (benefits minus project costs). The Corps calculated project costs for the eight projects, such as planning, design, construction, and maintenance costs. It calculated damage reduction benefits for seven projects by estimating reduced damages to existing structures in the project area, including to homes and commercial buildings. Corps guidance allows the economic analysis to also include incidental benefits of a project, and four projects incorporated recreational benefits of alternatives, such as increases in recreational visits because beaches would be larger. The Corps did not include other types of incidental benefits, such as environmental or other social benefits, for the eight projects. Corps documentation for one project identified environmental benefits of constructing wetlands as part of the project, such as improving ecosystems and filtering water. However, Corps officials said they did not incorporate these benefits into the economic analysis because the benefits could not be monetized.

The Corps faces challenges in developing cost and benefit information for some types of natural infrastructure and has initiated steps to address this. For example, a 2015 Corps report identified knowledge gaps in understanding how natural coastal infrastructure, such as wetlands, may perform during coastal storms. These knowledge gaps make it challenging for the Corps to develop cost and benefit information for some natural infrastructure alternatives and compare them to other alternatives, such as those that use hard infrastructure. The Corps recognizes the need to obtain additional data to better develop cost and benefit information and has begun taking steps to do so. For example, in 2018, the Corps initiated a project to help identify natural infrastructure knowledge gaps and prioritize key areas for research. The Corps plans to incorporate information gathered from this project into a strategic plan that is intended to help inform research funding decisions for fiscal year 2020, according to a Corps official.

Coastal areas are home to a considerable portion of the U.S. population,  with about 40 percent of the population living in coastal shoreline counties  and contributing to the production of $8.3 trillion of goods and services  annually. Coastal storms and flooding pose significant risks to coastal  communities and may cause substantial property damage. For example,  according to the National Oceanic and Atmospheric Administration  (NOAA), the three largest hurricanes during the 2017 Atlantic hurricane  season caused an estimated $265 billion in damage in the United States.  Moreover, according to the U.S. Global Change Research Program’s  2018 Fourth National Climate Assessment, damage to coastal areas from  extreme weather events combined with rising sea levels threaten  approximately $1 trillion in national wealth held in coastal real estate.

State and local governments have primary responsibility for managing  U.S. coastlines, but the federal government plays a key role in  implementing projects to reduce coastal risks from storms and floods. In  particular, the U.S. Army Corps of Engineers (Corps), within the  Department of Defense, constructs water resources projects to help  reduce the risks from coastal storms and flooding as well as to meet other  objectives, including restoring ecosystems and maintaining navigation  throughout the nation’s ports and waterways. For decades, the Corps has  used hard infrastructure (e.g., seawalls and levees) as well as beaches  and dunes to help reduce the risks from coastal storms and flooding. The  Corps also helps to repair infrastructure damaged by natural disasters.  For example, in response to natural disasters in 2017, the Corps  allocated approximately $645 million in supplemental appropriations for  emergency repairs for flood control and coastal risk reduction projects.

Over the last several years, some federal, state, and local governments,  as well as nongovernmental organizations and academia, have  increasingly supported using natural infrastructure as an alternative to  hard infrastructure for reducing risks in coastal areas. Natural  infrastructure includes (1) natural features that may provide coastal risk  reduction and that are created over time by physical, biological, geologic,  and chemical processes operating in nature or (2) nature-based features  created by human design, engineering, and construction to provide  specific services, such as coastal storm risk reduction. Natural  infrastructure may involve using a variety of natural features, including  beaches, dunes, wetlands, reefs, and aquatic vegetation. Natural features  can also be combined with hard infrastructure to create a hybrid approach  for reducing the risks to coastal areas from coastal storms and flooding.  Studies have shown that using natural features, such as wetlands and  marshes, can help reduce the risks to coastal communities from storms  and flooding and provide other benefits, such as support for fisheries,  recreational opportunities, and carbon sequestration.

You asked us to review the uses, costs, and benefits of natural coastal  infrastructure for the Corps’ coastal storm and flood risk management  projects. This report describes (1) how the Corps considered costs and  benefits for selected projects that used natural infrastructure and (2)  challenges the Corps faces in developing cost and benefit information for  using natural infrastructure and steps taken to address them.

To describe how the Corps considered costs and benefits for selected  projects that used natural infrastructure, we reviewed Corps guidance on  its process for planning water resources projects. We also obtained  descriptive information—such as the location, purpose, and types of  infrastructure used for projects—from each of the Corps’ coastal districts  that used natural infrastructure and had expenditures from fiscal years  2012 through 2017. We compiled this information into a list of 179  projects and analyzed it to select specific projects for further review. From  this list, we excluded projects without a coastal storm or flood risk  reduction objective. This resulted in 79 projects with coastal storm and  flood risk management objectives. To select specific projects for further  review, we then categorized projects by Corps district to identify districts  with the highest number of coastal storm and flood risk management  projects. We separated districts by their coastlines (Atlantic, Gulf, and  Pacific) and selected the district on each coastline with the highest  number of projects. For each selected district, we randomly selected  two projects with a coastal storm and flood risk management objective for  review, for a total of eight projects (see table 1).

For each of the eight projects, we obtained and analyzed information on  (1) the location and purpose of the project, (2) how the Corps identified  and considered project alternatives, and (3) the economic analysis  conducted. For example, to analyze the Corps’ economic analysis, we  reviewed the types of costs and benefits the Corps analyzed for each  project, and whether the Corps used standard approaches of economic  analysis outlined in the agency’s guidance, such as comparing project  results to expected conditions without the project. We interviewed Corps  officials at the districts with knowledge of the projects and relevant Corps  policies. In addition, we interviewed nonfederal sponsors for three  projects with planning documentation issued since 2007 (10 years prior to  our review) for their perspective on how the Corps considered the costs  and benefits for the projects. The findings from our analysis of the eight  selected projects are not generalizable to all Corps projects with coastal  storm and flood risk management objectives, but provide illustrative  examples of how the Corps considers the costs and benefits for a  geographically diverse range of randomly selected projects that used  natural infrastructure. See appendix I for more information about the eight  projects we reviewed.

To describe challenges in developing cost and benefit information for  using natural infrastructure, we conducted a literature review, reviewed  Corps documents related to the use of natural infrastructure, and  interviewed Corps officials and stakeholders with experience in using  natural infrastructure. To conduct the literature review, we searched the  ProQuest, Scopus, Organisation for Economic Co-operation and  Development, and the World Bank databases for economic articles using  search terms such as coastline, natural infrastructure, and green  infrastructure. Our initial searches identified 98 studies that we reviewed  to determine if they were (1) published after 2010, (2) peer reviewed, and  (3) focused on analyzing the economic costs and benefits associated with  using natural infrastructure for coastal storm and flood risk reduction in  the United States. Based on the application of these criteria, we identified  six studies that met our selection criteria for in-depth assessment. To  review these studies, we compared their assessment of benefits and  costs of using natural coastal infrastructure with relevant federal  guidelines and leading practices established by the Office of Management  and Budget, GAO, and others. Specifically, we assessed the extent to  which the studies included the elements of an economic analysis as  defined in GAO’s Assessment Methodology for Economic Analysis and  consistent with Office of Management and Budget Circular A-94. Based  on our review, we determined that the six studies are sufficiently reliable  for purposes of this report.

In addition, we reviewed Corps documents identifying challenges  associated with using natural infrastructure. We also interviewed Corps  officials with experience in researching natural infrastructure and  constructing projects about any challenges related to using natural  infrastructure. Finally, we interviewed a nongeneralizable selection of  stakeholders to obtain additional perspectives on any challenges related  to identifying the costs and benefits of using natural infrastructure. We  identified stakeholders from our review of economic literature.  Specifically, stakeholders we interviewed included officials from NOAA’s  Office for Coastal Management and researchers from the University of  California Santa Cruz, the University of Minnesota, the Environmental  Defense Fund, and The Nature Conservancy. To identify any steps the  Corps has taken to address these challenges, we interviewed Corps  officials from the Civil Works Directorate and the Engineer Research and  Development Center about the agency’s initiatives and obtained  supporting documentation, where available. In identifying challenges  associated with natural coastal infrastructure, we recognize that the  Corps may face other challenges in certain situations that we did not  identify through our document review, literature review, or interviews.

We conducted this performance audit from July 2017 to March 2019 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform our audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.

Coastal communities face hazards from coastal storms and flooding that  can cause loss of life, property damage, and damage to the environment.  More specifically, coastal communities face threats from erosion and  damages from waves, wind, and storm surges. For example, during  Superstorm Sandy in 2012, shoreline water levels rose across the East  Coast, causing billions of dollars in property damage to homes and  businesses. These threats can be exacerbated by several factors,  including sea level rise and commercial and residential development,  according to Corps documents on coastal risk reduction and resilience.  For example, rising sea levels increase the risks from regular tidal  flooding and coastal storms and new construction along coastlines can  increase the number of people and buildings at risk from the storms.

The Corps constructs projects to help reduce the risks from coastal storm  hazards and mitigate erosion, wave damage, and flooding, which may  include the use of hard structures. The Corps has decades of experience developing projects that use hard structures, such as  revetments, seawalls, and storm surge barriers, to reduce the risks from  coastal storm hazards, according to a 2014 report by the National  Academy of Sciences (see fig. 1).

Natural infrastructure can also be designed and developed for coastal  storm and flood risk reduction purposes. Natural infrastructure can involve  several types of natural features that have the potential to reduce risks to  coastal areas from storms (see fig. 2). Diverse natural features occur in  different areas of the United States. For example, some areas along the  Florida Gulf Coast are host to mangroves—coastal wetlands found in  tropical and subtropical regions—that can reduce the impacts of high  energy waves from storm surges. The extent to which natural  infrastructure can reduce risks to coastal areas from storms and flooding  depends on the types of natural features being used. For example,  underwater vegetation, such as seagrass, has less capacity to reduce  wave energy than a coral reef, which is a hard underwater structure,  according to scientific studies.

According to a 2014 National Academy of Sciences report, in addition to  reducing the risks of storms and flooding for coastal communities,  projects using natural infrastructure may provide other benefits,  depending on the type of natural feature associated with the project.  Among other things, natural infrastructure has the potential to enhance  commercial and recreational fisheries and create recreational  opportunities. For example, natural infrastructure may support fish  habitats, which could enhance a commercial or recreational fishery. In  addition, wetlands may improve habitats for birds, which could enhance  bird watching activities. Similarly, replenishing beaches may provide more  beach area for individuals to use for recreational activities, and provide  nesting habitat for birds and sea turtles.

The Corps’ Civil Works program—responsible for water resources  projects—is organized in three tiers: a national headquarters in  Washington, D.C.; eight regional divisions; and 38 districts (see fig. 3).

Corps headquarters primarily develops the policies and guidance that the  agency’s divisions and districts carry out as part of their oversight  responsibilities for the water resources projects under the Corps’ purview.  Corps districts are responsible for planning, engineering, constructing,  and managing water resources projects in their districts, including  projects that consider or use natural infrastructure.

The Corps has several programs and initiatives related to using natural  infrastructure for water resources projects. For example, the Engineer  Research and Development Center, the research organization within the  Corps, manages a portfolio of research related to water resources  projects that includes research focused on flood risk management and  coastal systems. The Corps also has an initiative called Engineering With  Nature®, which the Corps’ scientists and engineers developed to facilitate  using sustainable practices in Corps projects.

The Corps’ Water Resources Project Planning Process

The Corps develops water resources projects, including coastal storm  and flood risk management projects, in conjunction with nonfederal  sponsors, such as state and local governments. According to Corps  guidance, the planning process for these projects begins with a  nonfederal sponsor identifying a problem and approaching the Corps to  help develop a solution. Upon statutory authorization for a study and  appropriations to fund it, the Corps and the nonfederal sponsor enter into  an agreement to conduct a feasibility study for a potential project.  Nonfederal sponsors are to participate in the planning process, as well as  remain involved through project design, construction, and post-project  operations and maintenance. For example, for projects where the Corps  constructs hard infrastructure, such as a seawall, the nonfederal sponsor  is to assume responsibility for monitoring and maintenance costs  associated with the seawall after its construction. In contrast, for a project  that involves replenishing a beach, the Corps and the nonfederal sponsor  usually share the cost of replenishment for a specific period of time,  typically 50 years.

The U.S. Water Resources Council’s 1983 Economic and Environmental  Principles and Guidelines for Water and Related Land Resources  Implementation Studies (Principles and Guidelines) outline the standards  and procedures that the Corps is to follow for planning water resources  projects, including those with coastal storm and flood risk management  objectives. The Principles and Guidelines establish that the federal  objective of water resources projects is to contribute to national economic  development while protecting the nation’s environment. The Corps  implements the planning process outlined in the Principles and Guidelines  by conducting feasibility studies for proposed water resources projects.  The Corps’ Planning Guidance Notebook (Planning Guidance) provides  detailed guidance on how to implement the general process outlined in  the Principles and Guidelines for planning water resource projects. The  Corps’ feasibility study process includes four major phases and five  milestones, as shown in figure 4.

The Corps initiates a feasibility study by forming a project team,  comprising Corps engineers, economists, planners, and other specialists,  to conduct the study. The Corps project team begins with a scoping  phase that specifies the problem, such as the potential for coastal storm  and flood damage, and identifies opportunities for a project to address the  problem. The project team then inventories conditions in the project area,  including physical, economic, and social conditions, and forecasts how  these conditions may change over the life of a potential project. As it  continues the scoping phase, the project team identifies various  measures that could address the problem, such as replenishing an  existing beach or constructing a seawall. The project team then develops  potential individual measures or combinations of measures (e.g., beach  replenishment and seawall construction) into an initial list of alternatives.

Since 2016, the Corps has been required by statute to consider natural  infrastructure in certain circumstances.

With its initial list of alternatives, the Corps project team is to then  evaluate each alternative by (1) comparing it to the scenario of  proceeding with no project; (2) applying criteria established in the  Principles and Guidelines; (3) identifying beneficial and adverse effects  of each alternative; and (4) considering other relevant factors, such as  compliance with environmental requirements. To identify beneficial and  adverse effects of each alternative, the Corps uses four general  categories established in the Principles and Guidelines, as shown in table  2. The Corps’ Planning Guidance states that project teams should  evaluate alternatives using the four categories of analysis, but the  evaluation from two categories—National Economic Development and  Environmental Quality—must be included in each feasibility study.  According to the Planning Guidance, evaluating projects’ potential costs  and benefits through these categories of analysis provides a basis for  determining which alternatives should be eliminated from consideration,  modified, or selected for further analysis. This evaluation can eliminate  alternatives that do not meet planning objectives and may narrow the  initial list of alternatives to a final list for more detailed analyses and  comparison. Corps officials stated that the process of evaluating  alternatives can be iterative and is project specific.

The Corps project team then is to conduct detailed analyses of its final list  of alternatives to compare them to each other and select a recommended  alternative. The project team includes the recommended alternative in a  draft report with its analysis. The draft report is made available for review  and comment by nonfederal sponsors, federal and state agencies, and  other stakeholders. The project team incorporates comments into the  report, as appropriate, and determines whether the agency will endorse  the recommended alternative. The project team finalizes its feasibility  study after internal review. The Corps then prepares a report  summarizing the proposed plan—known as the Chief’s report—and  submits it to Congress for consideration and potential authorization.

The Corps Typically Identified Project Costs and Damage Reduction Benefits for Selected Projects That Used Natural Infrastructure

Based on our review of Corps guidance and eight selected projects that  used natural infrastructure, we found that the Corps typically identified  project costs and damage reduction benefits in selecting the alternative,  although for some projects it also considered additional benefits, such as  recreational benefits. Once a Corps project team develops a final list of  alternatives in conducting a feasibility study for a particular project, the  project team is to conduct an economic analysis for each alternative. This  analysis allows the team to compare costs and benefits directly across  the alternatives, including alternatives using natural infrastructure, hard  infrastructure, or a combination of the two. Specifically, the project team is  to develop estimates for each project alternative’s net economic  benefits—benefits minus costs—to identify and select the project  alternative with the maximum net benefits. The Corps’ Planning Guidance  states that the Corps shall select coastal storm and flood risk  management projects determined to have the maximum net benefits.

Our review of Corps guidance and eight selected projects identified the  following costs and benefits that the Corps generally incorporated into its  economic analyses:

Project costs. According to the Corps’ Planning Guidance, project  costs include three categories: implementation costs, other direct  costs, and associated costs. Implementation costs, for example,  include planning and design, construction, construction contingency,  operations, maintenance, repair, and other costs necessary to  implement a project. The eight selected projects that we reviewed  included analyses of project costs, which mostly focused on  implementation and interest costs. For example, the costs for the  Corps’ Jacksonville District Lido Key project included initial  construction costs (i.e., beach construction and hard infrastructure  designed to reduce shore currents), future beach replenishment costs  (i.e., operations related to placing material on beaches to replenish  eroding shores), and monitoring costs (e.g., measurement of beach  fill, sediment type, and habitat quality).

Damage reduction benefits. Reducing damages to existing  structures, including homes and commercial buildings, is the primary  benefit the Corps considers when identifying benefits for coastal storm  risk management project alternatives, according to the Corps’  Planning Guidance. The guidance outlines general steps for  estimating damage reduction benefits, which are to be calculated and  included in each coastal storm and flood risk management  alternative’s economic analysis. In seven of the eight projects we  reviewed, the Corps analyzed damage reduction benefits as part of its  economic analysis. For example, the Corps’ project team for the  New York District Union Beach project determined the potential  damage reduction benefits of each alternative by estimating the  alternative’s potential to reduce (1) damages to coastal property from  flooding and waves, (2) public emergency spending, and (3)  administrative costs for the National Flood Insurance Program (see  fig. 5).

We also found that for some selected projects, the Corps identified and  incorporated additional benefits into the projects’ economic analyses,  including the following:  Incidental recreational benefits. Corps project teams may include in  the economic analysis recreational benefits that stem directly from the  project alternative but that are incidental to the primary purpose of  damage reduction, according to the Corps’ Planning Guidance.  Specifically, Corps project teams may include recreational benefits,  such as increases in recreational visits because beaches are larger in  their economic analysis of project alternatives, but recreational  benefits are limited to no more than 50 percent of the total economic  benefits used to justify an alternative (i.e., demonstrate that an  alternative has greater benefits than costs). After an alternative has  been economically justified, the team can use the full estimated  recreational benefits with the damage reduction benefits to select the  alternative with maximum net benefits. In our review of eight projects,  we identified four projects where the Corps project team included  recreational benefits in its economic analysis for the project alternative  that was selected. For one such project, the Los Angeles District’s  Encinitas-Solana Beach project, the Corps’ economic analysis  showed that the selected project alternative had lower damage  reduction benefits than project costs. However, when the Corps  added recreational benefits—as allowed by Corps policy—the  combined annual damage reduction and recreational benefits resulted  in the alternative having greater benefits than costs (see fig. 6).

Other direct incidental benefits. The Corps may also consider other  direct incidental benefits in its economic analysis, as appropriate,  according to the Principles and Guidelines. In our review of eight  projects, we identified three projects that included estimated incidental  benefits aside from recreational benefits. The three projects included  economic benefits associated with reduced maintenance costs for  local communities, whose expenses for maintaining local beaches  would decline after the Corps projects were constructed. Other than  these reduced maintenance costs, the Corps did not include other  types of direct incidental benefits, such as environmental or other  social benefits, in the economic analyses for the eight projects we  reviewed. According to Corps officials, some project alternatives using  natural infrastructure may provide direct incidental benefits that are  not included in the economic analysis, such as environmental and  social benefits. For example, the draft feasibility study for the New  York District’s Jamaica Bay project states that natural infrastructure  can provide direct incidental benefits, such as improving ecosystems,  filtering water, and improving aesthetics. The Corps acknowledged  these incidental benefits and their importance to communities in its  draft feasibility study, but did not incorporate these benefits into its  economic analysis because they could not be monetized, according to  Corps district officials. Corps headquarters officials said incidental  benefits that cannot be monetized in the economic analysis are  considered in the planning process through the evaluation of other  Principles and Guidelines categories.

Two reports published by the National Academy of Sciences stated that  when assessing project alternatives, the Corps primarily uses qualitative  measures to assess benefits that are difficult to monetize but that  relegates such effects to secondary status compared to the monetized  estimates of costs and benefits. Moreover, a 2004 National Academy of  Sciences report found that the Principles and Guidelines outlines a  process that focuses on the effects that can be monetized, which does  not allow for full consideration of a project’s total economic effects.

Nonetheless, for three of the eight projects we reviewed, we found that  the Corps modified its approach in selecting the use of natural  infrastructure as part of the recommended alternative. For instance, for  the Encinitas-Solana Beach project, the Corps granted an exception to its  planning process and recommended a locally preferred plan. In certain  circumstances, Corps project teams can deviate from the Corps’ Planning  Guidance that calls for the Corps to select the project alternative with the  maximum net benefits. Corps headquarters officials said that requesting  such an exception is the primary method the agency uses for  recommending a project alternative that does not meet the Corps  maximum net benefits requirement for a project focused solely on coastal  storm or flood risk management. For the Encinitas-Solana Beach project,  the California Coastal Commission found that the Corps’ proposed  alternative with the maximum net benefits was inconsistent with the  mission of California’s coastal management program to protect and  enhance the state’s coastal environment. In particular, the Commission  had concerns about the size of the project and the amount of sand to be  added to the beach under the proposed alternative, as well as the  potential adverse effects on a nearshore natural reef and marine  resources. In response, the Corps’ Los Angeles District worked with the  project’s nonfederal sponsors to address the commission’s concerns and  revised the project by reducing its size and potentially lessening its  environmental impacts. The commission approved the revised project  alternative in November 2013.

The Corps’ Planning Guidance also allows projects with multiple  objectives to incorporate other analyses in selecting a recommended  alternative. For the Philadelphia District’s Lower Cape May project,  ecosystem restoration was the project’s primary objective, but it also had  a coastal storm risk management objective. According to the project’s  feasibility study, the project focused on protecting and restoring a  freshwater marsh that was being flooded with salt water from storms  because of continued beach erosion. The Corps used a cost- effectiveness analysis to meet the primary objective, which compared  environmental measures (e.g., the number of acres of habitat restored)  with the costs of different alternatives. In addition, this project included a  beach component to protect the marsh from saltwater intrusion. In the  process of designing beach alternatives, the Corps project team  conducted a damage reduction benefit analysis to determine an optimal  size for the beach that would provide the greatest net damage reduction  benefit to nearby communities. This analysis helped inform the Corps  decision to select a beach design option that met the project’s primary  objective of protecting the ecosystem, while also providing the most  incidental damage reduction benefits to local communities, according to  Corps district officials.

For the third project, the New York District’s Jamaica Bay project, the  Corps incorporated natural features into the project, although it did not  directly include the economic benefits of these features in its economic  analysis. For the project, the Corps project team recommended an  alternative that was designed to address frequent flooding within Jamaica  Bay at three locations. The project team incorporated wetlands into the  design at one location, along with hard infrastructure. The nonfederal  sponsors of the project told us that they advocated for the inclusion of  these natural features, where appropriate, because of their risk reduction  and ecological benefits. In response to the interests of nonfederal  sponsors, the Corps project team developed and recommended the  alternative incorporating hard infrastructure, such as floodwalls, along  with coastal wetlands. The Corps did not include the risk reduction  benefits from the wetlands in the economic analysis, but the draft  feasibility study noted that the project was economically justified based on  the monetary benefits of the hard infrastructure alone and that the  wetlands provided additional benefits that could not be monetized.

The Corps Faces Challenges in Developing Cost and Benefit Information for Some Types of Natural Infrastructure and Has Initiated Steps to Address Them

Based on our literature review, agency documentation, and interviews  with Corps officials and other stakeholders, we found that the Corps faces  challenges developing cost and benefit information for some natural  infrastructure to help inform the process for selecting project alternatives  and conducting economic analyses in feasibility studies. Specifically,  these challenges related to (1) assessing the performance of some types  of natural infrastructure and (2) monetizing the social and environmental  benefits associated with using natural infrastructure. The Corps  recognizes the need to obtain additional data to better develop cost and  benefit information for some types of natural coastal infrastructure, and it  has begun taking steps to do so.

Challenge in Assessing the Performance of Some Types of Natural Infrastructure

Information is not readily available on the performance of some types of  natural features in reducing coastal storm and flood damages, which  makes it challenging for the Corps to develop cost and benefit information  for these features and compare them to other alternatives, such as those  that use hard infrastructure. For example, Corps headquarters officials  said that—in contrast to beaches and dunes—there are significant  knowledge gaps about the extent to which wetlands, reefs, and  subaquatic vegetation can reduce the risks associated with coastal  storms by, for example, moderating wave heights and flooding. In  addition, there are knowledge gaps about how these natural features will  change over time and how any changes might affect the long-term  performance of the features.

A Corps report from January 2015 also identified knowledge gaps in  understanding how some natural infrastructure, such as wetlands, may  perform during coastal storms or floods. According to the report,  wetlands may reduce storm surge, but in some instances water can be  redirected, potentially causing a storm surge increase elsewhere. Corps  officials noted that all structures—whether natural or hard—change over time, requiring maintenance and repair, but said that natural infrastructure  may change more dramatically than hard infrastructure and over a shorter  period of time. For example, a healthy wetland could restore itself and  reduce maintenance costs after a major storm or require the Corps to  take action to restore the wetland after the storm event, which could  increase the costs of maintaining the wetland. Corps officials also stated  that there are knowledge gaps regarding whether wetlands can absorb  major storm surges and how these features would perform in the event of  recurring coastal storms in a short period of time. Specifically, natural  features may be damaged during intense storms (e.g., wetlands can  erode and vegetation may be stripped apart), which may degrade the  long-term performance of the features.

Because the Corps does not have information on performance for some  natural features, it has been unable to update engineering guidance to  include the use of some natural features, according to Corps officials. A  Corps headquarters official explained that the agency must first develop a  broader understanding of how some natural features, such as wetlands,  perform under various coastal storm scenarios over time before it can  begin to develop design guidance for using these features for coastal  storm protection and flood risk management projects.

A Corps headquarters official said that the agency recognizes the need to  obtain additional information on natural infrastructure and has initiated  steps to address the challenge related to developing information on the  performance of some types of natural infrastructure. In particular, in  October 2016, the Engineer Research and Development Center began  collaborating with several entities, including other federal agencies,  international partners, academic institutions, and nongovernmental  organizations, to develop guidelines for using some types of natural  infrastructure. According to the scoping document, this effort is to entail  developing guidelines to support various phases of building natural  infrastructure projects, including conceptualization, design, engineering,  construction, and maintenance. According to the Corps official, an  anticipated key output from the international effort includes developing  information on defining performance for different types of natural  infrastructure features and options for measuring performance depending  on project objectives. The final product is expected to include chapters  with information on analyzing natural infrastructure benefits and related  monitoring, maintenance, and adaptive management issues, among  others.

The Corps official stated that the guidelines will not be official Corps  guidance or policy, but Corps project teams and other practitioners can  use the guidelines as a resource for identifying best practices in planning  projects and assessing potential alternatives. For example, the guidelines  will include case studies illustrating design and engineering concepts for  certain types of natural features. The guidelines are scheduled for  publication in March 2020.

The Corps has also developed a separate internal initiative to help fill  knowledge gaps regarding how some natural features’ performance can  provide benefits relevant to flood risk management, among other benefits.  Specifically, the Corps’ Engineering With Nature® Initiative is focused on  sharing natural infrastructure best practices that are emerging, and  communicating the information to staff in the Corps’ district offices and  other key stakeholders. According to a Corps official, the goal of this  initiative, among other things, is to help familiarize the Corps’ district staff  with existing natural infrastructure information and relevant case studies.  The Corps’ Galveston and Philadelphia Districts have projects that may  incorporate natural infrastructure. For example, the Galveston District is  considering opportunities through the Coastal Texas study to use  natural features, such as barrier islands, wetlands, and reefs, in  combination with hard infrastructure (e.g., levees), to reduce the risks  from storms and floods. Similarly, the Corps’ Philadelphia District is  considering a plan to design, construct, and evaluate natural features as  part of the New Jersey Back Bays Storm Flood Risk Management  study.

In addition, in 2018, the Corps’ coastal working group initiated a project  within the Corps to help identify natural infrastructure knowledge gaps  and prioritize key areas for research based on requests for information  received from Corps’ districts. The Corps plans to incorporate  information gathered from this project into a strategic plan that is intended  to help inform research funding decisions for fiscal year 2020, according  to a Corps official.

Challenge in Monetizing Environmental and Social Benefits

Our review of economic literature identified challenges in estimating the  total economic benefits associated with using natural infrastructure  features. Several studies noted that data for conducting economic  analyses are not readily available. For example, one study noted that  there is insufficient information on how restoring wetlands might affect the  survival of certain endangered species. Such information is needed,  according to the study, to provide insight on the extent to which such  features might generate economic benefits. Another study noted that  because projects that combine natural features with more traditional  structures (i.e., hybrid projects) are relatively new, less is known about  their effectiveness or their costs and benefits. Finally, according to  another study, estimating recreational benefits associated with natural  habitats, such as coastal marshes, can be difficult because there is  insufficient information about the extent to which the public visits those  sites.

In the eight projects we reviewed, Corps project teams did not estimate  incidental benefits other than recreational benefits or through avoiding  maintenance costs for coastal storm and flood risk management projects.  As previously discussed, environmental and social benefits are  considered incidental benefits, and Corps guidance indicates that they do  not have to be included in the economic analysis. On the other hand,  when assessing potential alternatives of coastal storm and flood risk  management projects in its feasibility studies, the Corps can quantify or  describe the benefits qualitatively and consider these effects during the  planning process, outside of the economic analysis. For example, the  Corps has measures to quantify changes in habitat, such as number of  acres of wetlands restored. The Corps can also qualitatively describe  habitat benefits for specific species. However, these nonmonetized  benefits may not affect the selection of the recommended alternative,  which is generally based on the monetized net benefit estimates of each  proposed alternative.

The Corps has begun developing a process for identifying, describing,  and considering a broader array of potential benefits when assessing  natural infrastructure alternatives for specific projects. Specifically, a June  2017 memorandum from the Corps’ Director of Civil Works indicated that  projects with coastal storm and flood risk management objectives as well  as other objectives should consider social and environmental benefits in  the formulation, design, and implementation of projects within existing  legislation and Corps policy. A Corps headquarters official said that the  agency is not attempting to monetize all potential benefits but is  considering options for accounting for potential benefits other than  through the traditional monetary assessments of costs and economic  benefits. A Corps headquarters planning group is currently working on  developing an initiative that would identify a process for using a flexible  approach for considering the social and environmental effects of natural  infrastructure for coastal storm and flood risk management projects. For  example, project teams may have the option of determining whether to  incorporate nonmonetized social and environmental benefits, such as  enhancing public safety in coastal communities, into the decision-making  process for selecting the recommended alternative. The Corps official  stated that the agency has begun working on developing guidance for this  initiative and expects to issue the guidance in calendar year 2019.

We provided a draft of this report for review and comment to the  Department of Defense. The department provided technical comments,  which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the appropriate  congressional committees, the Secretary of Defense, the Chief of  Engineers and Commanding General of the U.S. Army Corps of  Engineers, and other interested parties. In addition, the report will be  available at no charge on the GAO website at http://www.gao.gov.

If you or your staff members have any questions regarding this report,  please contact me at (202) 512-3841 or fennella@gao.gov. Contact  points for our Offices of Congressional Relations and Public Affairs may  be found on the last page of this report. GAO staff who made key  contributions to the report are listed in appendix II.

Appendix I: Selected Projects with Coastal Storm and Flood Risk Management Objectives Using Natural Infrastructure

This appendix presents information on the eight projects that we selected  for review with coastal storm and flood risk management objectives that  the U.S. Army Corps of Engineers (Corps) constructed and that included  natural infrastructure. We randomly selected eight projects across Corps  districts on the Atlantic, Gulf, and Pacific coasts. In seven of the eight  projects, the Corps recommended alternatives with either beaches or  dunes as the type of natural features to be used for coastal storm and  flood risk reduction (see table 3). According to several Corps district  officials we interviewed, alternatives featuring beaches are often most  appropriate because other natural features, such as wetlands, would not  survive the impacts of the high-energy storm waves in open ocean  coastal areas where these projects are located.

Appendix II: GAO Contact and Staff Acknowledgments

In addition to the contact named above, Alyssa M. Hundrup (Assistant  Director), Leo Acosta (Analyst-in-Charge), Mark Braza, Eric Charles,  Timothy Guinane, and Jeanette Soares made key contributions to this  report. Important contributions were also made by John Delicath and Sara  Sullivan.

How does the Army Corps of Engineers determine when to use natural infrastructure (e.g. wetlands and beaches), or hard infrastructure (e.g., seawalls) for its coastal management projects?

For coastal storm and flood risk management projects, the Corps is supposed to choose the infrastructure type with the greatest net benefits.

However, it can be difficult to calculate the net benefits of natural infrastructure. For example, it can be hard to put a dollar value on environmental benefits such as providing habitat for fish and birds. Also, the Corps doesn't yet know exactly how some natural infrastructure may perform during coastal storms.


Maternal Mortality: Trends in Pregnancy-Related Deaths and Federal Efforts to Reduce Them

Every year in the United States, hundreds of women die of complications related to pregnancy and childbirth. According to CDC data, racial/ethnic disparities exist with regard to these deaths. For example, non-Hispanic black women were more than three times as likely to die as non-Hispanic white women, and non-Hispanic American Indian/Alaska Native women were more than two times as likely to die as non-Hispanic white women.

GAO was asked to review issues related to maternal mortality in the United States. In this report, GAO describes, among other things, (1) trends in pregnancy-related deaths in the United States, including trends in causes and timing of these deaths, and (2) HHS funding efforts focused on reducing pregnancy-related deaths.

GAO reviewed documentation about HHS's surveillance efforts related to pregnancy-related deaths; and analyzed CDC data on leading causes of pregnancy-related deaths from 2007 through 2016 (the most recent 10-year period available at the time of GAO's review). GAO also reviewed documentation and interviewed HHS and state public health officials in five selected states about HHS's funding efforts aimed at reducing pregnancy-related deaths, including select efforts used in these states. GAO selected these states primarily based on their geographic diversity and their implementation of select efforts to address maternal mortality. GAO provided a draft of this report to HHS. HHS provided technical comments, which GAO incorporated as appropriate.

GAO's analysis of the Centers for Disease Control and Prevention's (CDC) Pregnancy Mortality Surveillance System data shows that from 2007 through 2016, over 6,700 women died of causes related to or aggravated by their pregnancy—either while pregnant or within 1 year of the end of pregnancy. While CDC data show an overall increase in the pregnancy-related mortality ratio in the United States during this time frame, the annual ratio fluctuated. Cardiovascular conditions, infection, and hemorrhage were the leading causes of pregnancy-related deaths, and comprised about 50 percent of all pregnancy-related deaths from 2007 through 2016. In addition, CDC data show that the leading causes of pregnancy-related deaths differed by racial ethnic groups. (See figures.)

The Department of Health and Human Services has 13 ongoing efforts aimed at reducing pregnancy-related deaths. The following are key examples of these:

Supporting Maternal Mortality Review Committees Cooperative Agreements . According to CDC officials, in September 2019, CDC awarded 5-year cooperative agreements to 24 recipients covering 25 states with amounts ranging from $150,000 to over $550,000 in the first year, totaling about $8.4 million. Under these agreements, CDC is providing funding to state agencies and organizations that coordinate and manage Maternal Mortality Review Committees. The committees are responsible for comprehensively reviewing deaths to identify prevention opportunities.

Maternal and Child Health (MCH) Services Block Grant Program .The Health Resources and Services Administration provides funding through this program to 59 states and jurisdictions to improve maternal and child health. In fiscal year 2017, total expenditures for services for pregnant women from all sources—federal funds, as well as state, local, program income, and other funds—was about $300 million. According to agency officials, many recipients reported using their block grant funding to help support or complement other federal initiatives, such as their review committee, quality collaborative, and use of maternal safety bundles.

According to officials GAO interviewed in five selected states, they use these efforts and others collectively to address pregnancy-related deaths. For example, according to officials in one state, they implemented an obstetric hemorrhage maternal safety bundle in 2018 based on the state's Maternal Mortality Review Committee finding that hemorrhage was a leading cause of pregnancy-related deaths in the state. According to officials, the state's Maternal Mortality Review Committee was funded primarily through the MCH Services Block Grant.

All five states also mentioned beginning or continuing to address racial/ethnic or other health disparities with block grant funding, through their Maternal Mortality Review Committees, or other efforts. For example, officials in one state said they use block grant funding to support their Black Infant Health Program, which helps address maternal morbidity and mortality of black mothers in the late maternal period. Additionally, two of the HHS funding efforts awarded in fiscal year 2019 have outcomes related to decreasing racial and ethnic disparities in maternal mortality: the Alliance for Innovation on Maternal Health Community Care Initiative and the State Maternal Health Innovation Program.

Every year in the United States, approximately 700 women die of  complications related to pregnancy and childbirth, while thousands of  others experience life-threatening complications. In 2014, for example,  more than 50,000 women experienced a life-threatening pregnancy  complication, such as heart failure or cardiac arrest during surgery or a  procedure. While the maternal mortality ratio decreased globally by about  3 percent from 2000 through 2015, the ratio in the United States has  increased by about 3 percent for this time period.

Within the Department of Health and Human Services (HHS), the Centers  for Disease Control and Prevention (CDC) is the federal agency  responsible for surveillance—the continuous, systematic collection and  analysis of health-related data—of all deaths in the United States,  including pregnancy related-deaths. CDC data show that racial/ethnic and  age disparities exist in the rates of pregnancy-related deaths. For  example, from 2007 through 2016, non-Hispanic black women were more  than three times as likely to die than non-Hispanic white women, while  non-Hispanic American Indian/Alaska Native women were more than two  times as likely to die than non-Hispanic white women. (See fig. 1.)

Similarly, rates of pregnancy-related deaths for women 35 years old and  older are higher than the rates for women under 35 years old. (See fig. 2).

According to a Health Resources and Services Administration (HRSA)  report, access to consistent, high quality, and reliable data that identify  both the characteristics of women who die due to pregnancy  complications and the specific circumstances that lead to these deaths is  essential to inform critical action steps and for developing prevention  strategies. Such data can inform, for example, state and local efforts  funded by HHS to reduce these deaths.

You asked us to review issues related to maternal mortality in the United  States. This report describes  1.  HHS’s surveillance efforts related to maternal mortality;  2.  trends in pregnancy-related deaths in the United States, including  trends in the causes and timing of these deaths; and  3.  HHS funding efforts focused on reducing pregnancy-related deaths.

To describe HHS surveillance efforts, conducted by CDC, related to  maternal mortality in the United States, we reviewed agency  documentation, such as reports on maternal mortality. We identified three  such efforts—the National Vital Statistics System (NVSS), the Pregnancy  Mortality Surveillance System (PMSS) and the Maternal Mortality Review  Information Application (MMRIA). We also interviewed CDC and selected  state officials (see state selection criteria below).

To describe the trends in pregnancy-related deaths in the United States,  we analyzed PMSS data, including any age or racial/ethnic differences,  for these deaths from 2007 through 2016—the most recent 10-year  period available at the time of our review. We also analyzed PMSS data  on the timing of pregnancy-related deaths in the United States—whether  the death occurred during pregnancy or within 1 year of the end of the  pregnancy—for the period of 2011 through 2016. According to agency  officials, data on this variable were not collected by CDC until 2011. We  assessed the reliability of the PMSS data by (1) comparing PMSS data  provided to GAO with published reports, (2) reviewing existing  documentation on the data and the data collection processes that  produced them, and (3) interviewing agency officials knowledgeable  about the data. We determined that the PMSS data were sufficiently  reliable for our purposes.

To describe HHS funding efforts focused on reducing pregnancy-related  deaths, we reviewed agency documentation, such as agency notices of  funding opportunities and award announcements, and interviewed  officials at CDC, the Centers for Medicare & Medicaid Services, HRSA,  the Indian Health Service, the National Institutes of Health (NIH), and the  Substance Abuse and Mental Health Services Administration about their  efforts to reduce maternal mortality. HHS officials identified these  agencies as having efforts that may focus on reducing maternal mortality.  For our review, we identified ongoing funding efforts with a stated  outcome, goal or focus on reducing pregnancy-related deaths.

In addition, we interviewed state public health and vital records officials  from five selected states—California, Georgia, Illinois, Maryland, and  Texas—about their efforts to reduce maternal mortality. We selected  these states because of their geographic diversity and because these  states have a Maternal Mortality Review Committee (MMRC), which are  multidisciplinary committees whose goals are to systematically and  comprehensively review clinical and non-clinical information about  pregnancy-related deaths to develop recommended strategies for  preventing future deaths. a Perinatal Quality Collaborative (PQC), a network of multidisciplinary  teams that work to improve measurable outcomes for maternal and  infant health, and disseminate best practices. at least one of the maternal safety bundles implemented—sets of  evidence-based practices that when implemented collectively and  reliably in the delivery setting may improve patient outcomes and  reduce maternal mortality and severe maternal morbidity—that were  developed as part of the HRSA-supported Alliance on Innovation in  Maternal Health (AIM) initiative.

We conducted this performance audit from October 2018 through March  2020 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.

In the United States, deaths from all causes are recorded and tracked  through a multi-step registration process, which may vary by state,  according to CDC officials. According to CDC officials, when an individual  dies, a death certificate is filed with the state. Funeral directors are  responsible for providing demographic information about the deceased  individual, while physicians, coroners, and medical examiners are  responsible for providing information on cause of death. The local  registrar of vital statistics is responsible for verifying the information, and  then transferring copies of the death certificate to the city or county health  department in some jurisdictions, and to the state registrar. The state vital  registration office is responsible for verifying the information, maintaining  official copies, and creating an electronic record. According to CDC  officials we interviewed, state vital records offices submit their death  certificate information to CDC electronically.

In 2003, CDC revised the standard death certificate to include a checkbox  to indicate whether a woman was pregnant at the time of her death or up  to 1 year after delivery or end of pregnancy. (See fig. 3)

The checkbox is part of the medical portion of the death certificate that is  completed by a physician, coroner, or medical examiner. According to  CDC officials, there has been staggered adoption of the revised death  certificate by states, and not every state death certificate included the  pregnancy checkbox until 2019.

CDC Has Two National Surveillance Systems Related to Maternal Mortality and Has Created a Resource to Facilitate State Efforts

CDC collects maternal mortality data using two national surveillance  systems, NVSS and PMSS. In addition, CDC has developed a data  application that state or local MMRCs can use to centrally collect  information abstracted from various sources about each death.

Federal law directs CDC’s National Center for Health Statistics to collect  statistics on maternal mortality. According to CDC officials, the National  Center for Health Statistics receives copies of electronic records for  deaths from all states and jurisdictions, such as the District of Columbia. It  uses this death certificate information to assign ICD-10 codes based on  the cause of death. According to CDC officials, the National Center for  Health Statistics uses these coded records to compile national vital  statistics files in NVSS, which is the source of official statistics on  mortality in the United States, including maternal deaths. NVSS data are  used to identify national trends and make international comparisons.

CDC published national maternal mortality rates for deaths that occurred  in 2007 based on data collected in NVSS in its report on all deaths in the  United States. CDC also made these data publicly available in microdata  files that can be downloaded through website applications and, according  to officials, in response to specific requests when additional details, such  as geography, are sought. However due to staggered implementation of  the 2003 revised death certificate by the states and reliability concerns  about the use of the pregnancy checkbox, CDC officials said that as of  September 2019, they have not published NVSS statistics on maternal  mortality in the agency’s annual mortality reports since the report on  deaths that occurred in 2007. For example, as specified in the technical  notes of a June 2019 CDC report on national vital statistics for deaths in  2017, CDC noted evidence of an increase in false reporting of maternal  deaths as a result of incorrect completion of the pregnancy checkbox on  death certificates. According to CDC officials, the individual who  completed the pregnancy checkbox may have incorrectly noted that a  woman was pregnant or had been pregnant within 1 year of her death,  and as a result, the death would have been recorded as a maternal death  or late maternal death. However, prior to the addition of the pregnancy  checkbox, there was a general concern that the United States was not  identifying all of the maternal deaths and thus did not have a full picture of  maternal mortality.

According to CDC officials, the agency has recently taken steps to  improve NVSS data on maternal mortality. For example, in 2018, CDC  developed training for individuals who complete the cause of death  portion of a death certificate, and in 2019 was developing guidance on  completing the pregnancy checkbox. The agency also participated in a  quality assurance pilot from January 2016 through March 2017 with four  states, Georgia, Louisiana, Michigan, and Ohio, to test processes that  may improve state-level data on maternal mortality. The results of the  pilot were made available in articles in 2019, and CDC officials said the  agency is currently disseminating the findings from the pilot to other  states. According to agency officials, one of the findings from the pilot  was that a greater proportion of deaths where the pregnancy checkbox on  the death certificate was marked incorrectly were for women aged 45 and  older. As a result, CDC officials said they plan to use additional criteria  when classifying deaths for these women. Specifically, they will only code  the death as a maternal death or late maternal death if the cause of death  is explicitly reported on the death certificate as due to pregnancy or an  obstetric cause.

CDC officials stated that the changes they made improved the accuracy  of data on maternal mortality, and they will implement the new reporting  criteria for 2018 data. On January 30, 2020, CDC published maternal  mortality statistics in a National Vital Statistics Report. For data on  maternal mortality accessible through CDC’s website, CDC officials said  they will direct users of these data to its limitations that are noted in the  annual report. Officials said they will also publish guidance on the  limitations of the maternal mortality statistics, and they will continue to  monitor the accuracy of the data. Taking these steps to improve the  NVSS data on maternal mortality and noting their limitations should help  provide federal, state, and local organizations with accurate data. For  example, CDC notes on its CDC WONDER website that state, local, and  county health departments rely on this source of publicly accessible data  to review their community’s population health trends, evaluate their  program’s performance for planning purposes, and compare their  community with other locations.

In 1986, CDC initiated a second national surveillance system for maternal  mortality, PMSS. Unlike NVSS, PMSS is exclusively focused on  pregnancy-related deaths. According to CDC, the system was developed  because more clinical classification of the causes of these deaths was  needed in order to fill data gaps and help clinicians and public health  professionals to better understand circumstances surrounding pregnancy- related deaths, including the causes and appropriate actions to prevent  them. This collection effort included expanding the scope of deaths under  surveillance to those up to 1 year after the end of pregnancy, which is  beyond the international standard of up to 42 days after the end of a  pregnancy.

To collect the additional data, CDC officials annually send requests to  vital records offices for all 50 states and other applicable jurisdictions to  provide the following: death certificates, linked live birth or fetal death  certificates, and any other supporting information for 1) deaths with an  ICD-10 Chapter O code for the previous year, and 2) all deaths from any  cause (including injury or trauma) among women who were pregnant or  were within 1 year of pregnancy as identified by matching the death  certificate to a birth or fetal death certificate or by a pregnancy checkbox  on the death certificate. According to CDC officials and related literature,  linking information on death certificates to information on infant birth or  fetal death certificates can help confirm that the pregnancy checkbox on  the death certificate was completed accurately. In addition to confirming  validity of a pregnancy-related death as indicated by the checkbox, linking  information on death certificates to infant birth or fetal death certificates  can identify pregnancy-related deaths where the checkbox did not  indicate a pregnancy but should have (false negatives). CDC officials said  that PMSS data are considered the most reliable source of national data  on pregnancy-related deaths because (1) PMSS links death certificates  with birth or fetal death certificates and additional information when  available (e.g., hospital records), and (2) these files are reviewed by  medically trained epidemiologists to determine if the cause and time of  death are related to the pregnancy.

CDC publishes national data from PMSS on the leading causes of  pregnancy-related deaths and pregnancy-related mortality ratios using  this system. However, the data are not published annually—such as is  generally the case with NVSS data on deaths—and only national level  data are made publicly available from PMSS in annual updates on the  website and periodically in reports. According to agency officials, states  and jurisdictions voluntarily provide the records in response to CDC’s  request that specifies that PMSS analyses will only be published at the  national and regional level, and those records are subject to  confidentiality protections. Additionally, according to CDC officials,  because of the time involved in collecting documentation from states, the  most recent data available from PMSS as of September 2019 were for  deaths in 2016.

To improve the timeliness of PMSS data, CDC is taking steps to gain  access directly to the records that states have been submitting to the  agency. Specifically, CDC entered into a contract, effective August 2019,  for a pilot project with the National Association for Public Health Statistics  and Information Systems to become an approved user of the State and  Territorial Exchange of Vital Events system. According to the National  Association for Public Health Statistics and Information Systems, this vital  events system provides timely access to state vital records, including  records on deaths, to federal and state data partners for use in authorized  public health and administrative programs, like those at CDC. According  to the contract, over the next 5 years, select CDC staff will receive  training on the use of the system and will coordinate phased access to  state and jurisdiction vital records. At the conclusion of the contract,  authorized CDC staff are expected to have access to electronic vital  records data from up to 51 states and jurisdictions. CDC officials said this  should allow them to link birth and death certificate information and no  longer rely on states and jurisdictions to conduct vital records linkages for  PMSS. According to CDC officials, being able to access the vital events  system will allow them to confirm and report pregnancy-related deaths  with improved timeliness.

In 2017, CDC released MMRIA, in which MMRCs— multidisciplinary  committees at the state and other jurisdictional level that review  pregnancy-related deaths—can collect and review data from various  sources (e.g., medical records, social service records, autopsy reports,  and vital records) to determine preventability, and identify factors that  contributed to these deaths as well as prevention strategies to address  these factors. As of June 2019, CDC officials said that 25 states and  one other jurisdiction were using this system.

While MMRCs provide the information collected in MMRIA, federally  published reports only include aggregate information from select states  collected through the application. For example, in May 2019, CDC  published a study using information from 13 states. In the study, state  MMRCs identified an average of three to four contributing factors per  pregnancy-related death based on information collected through MMRIA,  such as:  community factors (e.g., unstable housing and limited access to  transportation); health facility factors (e.g., limited experience with obstetric  emergencies and lack of appropriate personnel or services); patient factors (e.g., lack of knowledge of warning signs and  nonadherence to medical regimens); provider factors (e.g., missed or delayed diagnosis); and  system-level factors (e.g., inadequate access to care and poor case  coordination).

Similar to PMSS data, the most current aggregated data that CDC  publishes from the MMRIA can be for deaths that occurred 2 or more  years prior to the date of the report. As noted in the May 2019 article, the  most recent information from states contributing to the article varied with  some state data on these deaths being as recent as 2017 while the most  recent data from other states was from 2014. According to CDC officials,  in August 2019, CDC awarded 24 cooperative agreements covering 25  states, and under these agreements, the committees will use the system  to record review results within 2 years of a death.

Data Show an Overall Increase in the Pregnancy-Related Mortality Ratio, with Specific Causes Varying by Race/Ethnicity, Age, and Other Factors

Our analysis of CDC’s PMSS data shows that from 2007 through 2016,  over 6,700 women died of causes related to or aggravated by their  pregnancy—either while pregnant or within 1 year of the end of  pregnancy. Our analysis also shows that while there was an overall  increase in the pregnancy-related mortality ratio during this time frame,  the annual mortality ratio in the United States fluctuated. As previously  noted, CDC data also show that racial and age disparities exist in the  rates of pregnancy-related deaths. For example, from 2007 through 2016,  non-Hispanic black women were more than three times as likely to die  than non-Hispanic white women, while non-Hispanic American  Indian/Alaska Native women were more than two times as likely to die  than non-Hispanic white women. Similarly, rates of pregnancy-related  deaths for women 35 years old and older are higher than the rates for  women under 30 years old. During this time period, the specific causes of  death varied by race/ethnicity and age. Further, CDC data show that most  of the deaths occurred within 42 days of delivery or the end of pregnancy.

Cardiovascular Conditions, Infection, and Hemorrhage Were the Leading Causes of Pregnancy-Related Deaths, though Causes Differed Among Racial/Ethnic and Age Groups

CDC’s PMSS data show that among all pregnancy-related deaths, the  cause of death varied. In general, what CDC classifies as “other  cardiovascular conditions” was the most common cause of pregnancy- related deaths, followed by infection, hemorrhage, and cardiomyopathy.  (See fig. 4.) These four leading causes comprised about 50 percent of all  pregnancy-related deaths from 2007 through 2016. See appendix I for  more information on leading causes of pregnancy-related deaths.

CDC data shows that the leading causes of pregnancy-related deaths  differed by racial/ethnic groups. Specifically, for non-Hispanic white and  black women, the leading cause was other cardiovascular conditions from  2007 through 2016; for non-Hispanic American Indian/Alaska Native and  Asian/Pacific Islander women, it was hemorrhage; for Hispanic women, it  was infection, as indicated by figure 5. CDC has reported that multiple  factors contribute to pregnancy-related mortality and to racial/ethnic  disparities, including community, health facility, patient/family, provider,  and system factors.

Leading causes of pregnancy-related deaths also differed by the age of  the woman, as indicated by figure 6. Specifically, the leading cause for  women under 25 was infection, while for all other women the leading  cause was other cardiovascular conditions. In a 2017 article, the authors  noted that maternal morbidity and mortality rates increase with advanced  maternal age, due in part to increased prevalence of chronic conditions  (e.g., hypertension, diabetes, and chronic heart disease.). This may  help explain the variation in the rate of pregnancy-related deaths among  women of different ages.

Most Pregnancy-Related Deaths Occurred within 42 Days of the End of Pregnancy, while Specific Causes of Death Varied Depending on When the Death Occurred

Our analysis of CDC’s PMSS data shows that from 2011 through 2016,  most pregnancy-related deaths occurred between 0 and 42 days  postpartum—meaning that they occurred either on the day of delivery or  end of pregnancy up to 42 days after pregnancy. (See fig. 7.) According  to CDC officials, understanding the timing of pregnancy-related deaths is  important for prioritizing intervention strategies. The officials noted that  deaths resulting from cardiomyopathy can occur months after pregnancy  but can also be prevented with appropriate interventions. In particular, the  American College of Obstetricians and Gynecologists published guidance  for managing pregnancy and heart disease that noted that complications  are frequently encountered in the days, weeks, and months after delivery  in women with known cardiovascular disease and in those with latent  cardiovascular disease. Women with multiple risk factors for  cardiovascular disease may be particularly at risk of manifesting  symptoms for the first time during their postpartum course.

CDC’s data show that the leading causes of pregnancy-related death  varied depending on when the death occurred. For example, over the  period 2011-2016, hemorrhage and amniotic fluid embolism were leading  causes of pregnancy-related deaths on the day of delivery or the end of  pregnancy, while cardiomyopathy was the leading cause of pregnancy- related deaths between 43 and 365 days postpartum. (See fig. 8.) A  recent article on pregnancy-related deaths stated that multiple factors  contribute to pregnancy-related deaths during pregnancy, labor and  delivery, and the postpartum period. Further, the article notes that no  single intervention strategy is sufficient, and reducing these deaths  requires reviewing and learning from each death, improving women’s  health, and reducing social inequities across the life span, as well as  ensuring quality care for pregnant and postpartum women, according to  the article. See appendix II for supplemental data on pregnancy-related  deaths.

HHS Funds Multiple Ongoing Efforts Focused on Reducing Pregnancy-Related Deaths

State Participation in the Alliance for  Innovation on Maternal Health (AIM)  Initiative  According to the American College of  Obstetrics and Gynecology, as of June 2019,  26 states were enrolled in the AIM initiative.  The AIM initiative, funded by the Health  Resources and Services Administration,  engages provider organizations, state-based  public health systems, consumer groups and  others in a national partnership to assist state- based teams in implementing evidence-based  maternal safety bundles.  Ten of the 26 states joined in the last year  and are beginning to implement maternal  safety bundles and collect data. Five of these  bundles are being implemented by one or  more states. Bundle topics: Maternal Venous  Thromboembolism, Postpartum Care Basics  for Maternal Safety: From Birth to  Comprehensive Postpartum Visit, Obstetric  Care for Women with Opioid Use Disorder,  Obstetric Hemorrhage, Reduction of  Peripartum Racial/Ethnic Disparities, Safe  Reduction of Primary Cesarean Birth, Severe  Hypertension in Pregnancy, and Postpartum  Care Basics for Maternal Safety: Transition  from Maternity to Well Woman Care.

Preventing Maternal Deaths: Supporting Maternal Mortality  Review Committees Cooperative Agreements. Under these  cooperative agreements, CDC is providing funding to state agencies  and organizations that coordinate and manage MMRCs. As  previously mentioned, MMRCs systematically and comprehensively  review pregnancy-related deaths in order to identify prevention  opportunities. Funding recipients will identify and review deaths  within 1 year of death and enter clinical and non-clinical data and  committee decisions in MMRIA—a standardized data system  managed by CDC—within 2 years of death. As part of the agreement,  recipients—in coordination with CDC—analyze data and share  findings with stakeholders, such as clinicians, to inform policy and  prevention strategies to reduce pregnancy-related deaths, such as  screening procedures. According to CDC officials, in August 2019,  CDC awarded these 5-year cooperative agreements to 24 recipients  covering 25 states. Recipients received different amounts ranging  from $150,000 to over $550,000 in the first year to support their  MMRC. CDC anticipates awarding a similar level of funding for the 5- year period of performance.

Maternal and Child Health (MCH) Services Block Grant Program.

HRSA provides funding through this program to 59 states and  jurisdictions to improve maternal and child health. According to  agency officials, many recipients reported using their MCH Services  Block Grant funding to help support or complement other federal  initiatives, such as an MMRC, a Perinatal Quality Collaborative  (PQC), and Alliance for Innovation on Maternal Health (AIM) maternal  safety bundles. For example, according to HRSA officials, in fiscal  year 2018, 38 recipients self-reported that the block grant partially or  fully funded their MMRCs, and additional states and jurisdictions  reported using block grant support for planning activities to begin  development of their MMRC. Further, states and jurisdictions cited  PQCs, networks of multidisciplinary teams that work to improve  measurable outcomes for maternal and infant health, in their block  grant narrative. Additionally, implementation of a HRSA-supported  AIM maternal safety bundle, sets of actionable, evidence-based  practices for improving maternal outcomes was cited. (Appendix III  includes more information on funding for PQCs and AIM maternal  safety bundles.) Our review of HRSA documentation shows that in  fiscal year 2017, total federal expenditures for the block grant program  were about $540 million for women and children covered by the  program, and expenditures for services for pregnant women from all  sources—federal funds, as well as state, local, program income, and  other funds—was about $300 million.

Indian Health Service (IHS) Implementation  of Alliance for Innovation on Maternal  Health (AIM) Maternal Safety Bundles  In 2017, IHS’s leadership released a request  that IHS federal hospitals that provide  inpatient obstetric care implement at least one  maternal safety bundle—sets of evidence- based practices that when implemented  collectively and reliably in the delivery setting  may improve patient outcomes and reduce  maternal mortality and severe maternal  morbidity. According to IHS, since 2014, IHS  has had phased implementation of the  bundles in federal hospitals that provide  inpatient obstetric care.   Officials said that for many facilities, Obstetric  Hemorrhage was the first bundle  implemented. Others have also been  implemented, such as the Severe  Hypertension in Pregnancy bundle, and the  Obstetric Care for Women with Opioid Use  Disorder bundle.

According to officials we interviewed in five selected states, they use  these two efforts—MMRC findings and MCH block grant funding—and  other efforts collectively to address pregnancy-related deaths. For  example, according to Georgia officials, Georgia’s PQC received funding  from CDC and implemented the AIM obstetric hemorrhage maternal  safety bundle in 2018 based on the state’s MMRC finding that  hemorrhage was a leading cause of pregnancy-related deaths in Georgia.  According to officials, Georgia’s MMRC was funded primarily through the  MCH Services Block Grant. Similarly, according to Maryland officials,  Maryland’s PQC oversees implementation of the state’s AIM initiative.  Officials we interviewed from three of the five selected states said that the  AIM initiative had an immediate or the largest effect on addressing  maternal mortality in their state. Officials from the other two states said  they could not identify which efforts had the largest or most immediate  effect on addressing maternal mortality. Officials from one state noted the  importance of their collaborative approach and the other noted that there  is no one contributing factor for maternal mortality. See appendix V for  more information about how the selected states we interviewed are using  these funding efforts.

All five states also mentioned beginning or continuing to address  racial/ethnic or other health disparities with block grant funding, through  their MMRCs, or other efforts. For example, officials in one state said they  use block grant funding to support its Black Infant Health Program, which  helps address maternal morbidity and mortality of black mothers in the  late maternal period. Additionally, two of the HHS funding efforts awarded  in fiscal year 2019 have outcomes related to decreasing racial and ethnic  disparities in maternal mortality: the Alliance for Innovation on Maternal  Health Community Care Initiative and the State Maternal Health  Innovation Program.

In addition to those efforts that are exclusive to maternal mortality or have  a focus on maternal mortality, HHS agencies have other funding efforts  that may reduce maternal mortality by improving maternal health. For  example, agency officials also identified the following:

HRSA’s Maternal, Infant, and Early Childhood Home Visiting Program  supports voluntary, evidence-based home visiting services for at-risk  pregnant women and parents with children up to kindergarten entry.  Our review of agency documentation shows that in fiscal year 2019,  HRSA awarded about $351 million in funding to 56 states, territories,  and nonprofit organizations to support communities in providing  voluntary evidence-based home visiting services through the  Maternal, Infant, and Early Childhood Home Visiting Program.

The Substance Abuse and Mental Health Services Administration,  which is responsible for leading public health efforts to advance the  behavioral health of the nation and reducing the impact of substance  abuse and mental illness on America’s communities. The agency  funds two programs that provide grants to public and private nonprofit  entities and state substance abuse agencies for substance use  disorder treatment and recovery services for pregnant and postpartum  women. Our review of agency documentation and interviews with  agency officials shows that from fiscal year 2017 through 2019, the  Substance Abuse and Mental Health Services Administration awarded  41 Services Grant Program for Residential Treatment for Pregnant  and Postpartum Women and six State Pilot Grant Program for  Treatment for Pregnant and Postpartum Women grants.

The Centers for Medicare & Medicaid Services, which administers the  Medicare and Medicaid programs, developed the Maternal Opioid  Misuse Model. Through this model, state Medicaid agencies will  coordinate with care-delivery partners to test whether payments for  evidence-based, coordinated care delivery improve outcomes and  reduce costs for pregnant and postpartum Medicaid beneficiaries with  opioid use disorder and their infants. According to agency officials,  funding for cooperative agreements with 10 state Medicaid agencies  began in January 2020.

We provided a draft of this report to HHS. HHS provided technical  comments, which we incorporated as appropriate.

As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies of this report to the  Secretary of HHS, and appropriate congressional committees. In addition,  the report will be available at no charge on the GAO website at  http://www.gao.gov.

If you or your staff have questions about this report, please contact me at  (202) 512-7114 or deniganmacauleym@gao.gov. Contact points for our  Offices of Congressional Relations and Public Affairs may be found on  the last page of this report. GAO staff who made major contributions to  this report are listed in appendix VI.

Appendix I: Pregnancy Mortality Surveillance System Cause of Death Categories

In 1986, the Centers for Disease Control and Prevention (CDC) initiated  national surveillance of pregnancy-related deaths in the Pregnancy  Mortality Surveillance System (PMSS) because more clinical information  was needed to fill data gaps about causes of these deaths. A pregnancy- related death, as defined in statute, is the death of a woman while  pregnant or within 1 year of the end of a pregnancy—regardless of the  outcome, duration or site of the pregnancy—from any cause related to or  aggravated by the pregnancy or its management, but not from accidental  or incidental causes.

As of September 2019, CDC used 11 categories when coding the cause  of death for pregnancy-related deaths in PMSS, and 2016 data were the  most recent data available. From 2007 through 2016, there were 6,765  pregnancy-related deaths, according to PMSS data. See table below for  information on the 11 cause of pregnancy-related death categories,  including PMSS data on leading causes, most common time frame, and  most common age group affected.

Appendix II: Supplemental Data on Pregnancy-Related Deaths

The following tables include supplemental data on pregnancy-related  deaths by racial/ethnic and age groups.

Appendix III: Ongoing Department of Health and Human Services Funding Efforts to Reduce Pregnancy-Related Deaths

As of September 2019, the Department of Health and Human Services  was providing funding for 13 efforts with a stated outcome, goal, or focus  on reducing pregnancy-related deaths. One of the these—Supporting  Maternal Mortality Review Committees—is funded by CDC and has an  exclusive focus on reducing deaths of the women during pregnancy or up  to 1 year of pregnancy, while the other 12 have additional focus areas,  such as improving infant health. Two of these efforts are not discrete  funding opportunities, but rather a variety of research funding  opportunities offered by the Health Resources and Services  Administration and the National Institutes of Health. Table 5 lists the 13  efforts, their current awards, funding, purpose, and examples of goals or  research.

Appendix IV: Health Resources and Services Administration and National Institutes of Health Research

Health Resources and Services Administration (HRSA) and National  Institutes of Health (NIH) officials noted research the agencies support,  including funding related to maternal health that also includes projects  specific to maternal mortality or that can affect maternal mortality.

The Maternal and Child Health Bureau supports field-based, applied and  translational research through an extramural research program that  provides leadership and funding that support innovative research to  inform practitioners, the scientific community, and the public. According to  HRSA officials, this research program helps to advance the field of  maternal and child health; improve the health and well-being of women,  children, and families; and address the needs of economically or  medically vulnerable maternal and child health populations.

According to HRSA officials, in fiscal year 2018, HRSA awarded a total of  about $1.2 million in funding for six research projects related to maternal  illness. The following HRSA website includes an option for searching for  funded projects using key terms, https://mchb.hrsa.gov/research/.

Baeva, S., D.L. Saxton, K. Ruggiero, et al. “Identifying Maternal  Deaths in Texas Using an Enhanced Method, 2012”, Obstetrics &  Gynecology, vol. 131, no. 5 (2018): 762-769.

Casey, M.M., P. Hung, C. Henning-Smith, et al. “Rural Implications of  Expanded Birth Volume Threshold for Reporting Perinatal Care  Measures.” Joint Commission Journal on Quality and Patient Safety,  vol. 42, no. 4 (2016): 179-187.

Hung, P., K.B. Kozhimannil, M.M. Casey, et al. “Why Are Obstetric  Units in Rural Hospitals Closing Their Doors?” Health Services  Research, vol. 51, no. 4 (2016): 1546-1560.

Kozhimannil, K.B., C. Henning-Smith, P. Hung, et al. “Ensuring  Access to High-Quality Maternity Care in Rural America.” Women’s  Health Issues, vol. 26, no. 3 (2016): 247-250.

Kozhimannil, K.B., P. Hung, M.M. Casey, et al. “Factors Associated  with High-Risk Rural Women Giving Birth in Non-NICU Hospital  Settings.” Journal of Perinatology, vol. 36, no. 7 (2016): 510-515.

Kozhimannil, K.B., M.M. Casey, P. Hung, et al. “Location of Childbirth  for Rural Women: Implications for Maternal Levels of Care.” American  Journal of Obstetrics and Gynecology, vol. 214, no. 5 (2016): 661e1- 10.

Kozhimannil, K.B., C. Henning-Smith, and P. Hung. “The Practice of  Midwifery in Rural US Hospitals.” Journal of Midwifery & Women’s  Health, vol. 61, no. 4 (2016): 411-418.

Kozhimannil, K.B., P. Hung, M.M. Casey, et al. “Relationship between  Hospital Policies for Labor Induction and Cesarean Delivery and  Perinatal Care Quality among Rural U.S. Hospitals.” Journal of Health  Care for the Poor and Underserved, vol. 27, no. 4 (2016): 128-143.

Weigel, P.A., F. Ullrich, D.M. Shane, et al. “Variation in Primary Care  Service Patterns by Rural-Urban Location.” Journal of Rural Health,  vol. 32, no. 2 (2016): 196-203.

NIH support research, including funding maternal health research through  a number of its institutes and centers, such as the Eunice Kennedy  Shriver National Institute of Child Health and Human Development; the  National Heart, Lung, and Blood Institute; the National Institute of Alcohol  Abuse and Alcoholism; the National Institute of Diabetes and Digestive  and Kidney Diseases; the National Institute of Mental Health; the National  Institute of Nursing Research, and the Office of Research on Women’s  Health. For example, NIH officials noted that The Eunice Kennedy Shriver  National Institute of Child Health and Human Development supports  essential research designed to overcome many of the complex  challenges that women encounter in trying to achieve and maintain  healthy pregnancies, and to prevent maternal mortality and severe  maternal morbidity.

In fiscal year 2018, NIH funded 661 projects totaling almost $303 million  that included a focus on maternal health. The following NIH website  includes a link to funded research for fiscal years 2015 through 2018 and  estimates for fiscal year 2019 and 2020 by category, including maternal  health, https://report.nih.gov/categorical_spending.aspx.

MacDorman, M.F., E. Declercq , and M.E. Thoma. “Making Vital  Statistics Count: Preventing U.S. Maternal Deaths Requires Better  Data.” Obstetrics & Gynecology, vol. 131, no. 5 (2018): 759-761.

MacDorman, M.F., E. Declercq, H. Cabral, et al. “Recent Increases in  the U.S. Maternal Mortality Rate: Disentangling Trends from  Measurement Issues.” Obstetrics & Gynecology, vol. 128, no. 3  (2016): 447-455.

Thoma, M.E., D.A. De Silva, and M.F. MacDorman. “Examining  Interpregnancy Intervals and Maternal and Perinatal Health Outcomes  Using U.S. Vital Records: Important Considerations for Analysis and  Interpretation.” Paediatric and Perinatal Epidemiology, vol. 33, no. 1  (2019): O60-O72.

Brogly, S.B., K.E. Saia, M.M. Werler, et al. “Prenatal Treatment and  Outcomes of Women with Opioid Use Disorder.” Obstetrics &  Gynecology, vol. 132, no. 4 (2018): 916-922.

Dimidjian, S., S.H. Goodman, J.N. Felder, et al. “Staying Well During  Pregnancy and the Postpartum: A Pilot Randomized Trial of  Mindfulness-based Cognitive Therapy for the Prevention of  Depressive Relapse/Recurrence.” Journal of Consulting and Clinical  Psychology, vol. 84, no. 2 (2016): 134-145.

Hauspurg, A., S. Parry, B.M. Mercer, et al. “Blood Pressure Trajectory  and Category and Risk of Hypertensive Disorders of Pregnancy in  Nulliparous Women.” American Journal of Obstetrics and Gynecology,  vol. 221, no. 3 (2019): 277.e1-277.e8.

Liu, T., M. Zhang, E. Guallar, et al. “Trace Minerals, Heavy Metals,  and Preeclampsia: Findings from the Boston Birth Cohort.” Journal of  the American Heart Association, vol. 8, no. 16 (2019): e012346.

Miller, E.C., M. Gallo, E.R. Kulick, et al. “Infections and Risk of  Peripartum Stroke during Delivery Admissions.” Stroke, vol. 49, no. 5  (2018): 1129-1134.

Sheen, J.J., J. D. Wright, D. Goffman, et al. “Maternal Age and Risk  for Adverse Outcomes.” American Journal of Obstetrics and  Gynecology, vol. 219, no. 4 (2018): 390.e1-390.e15.

Appendix V: Maternal Mortality Efforts in Selected States

To describe how selected states use Department of Health and Human  Services (HHS) funds to implement select efforts to reduce maternal  mortality, we interviewed officials from five states—California, Georgia,  Illinois, Maryland, and Texas—selected because of their geographic  diversity and because these state have the following efforts shown in  Table 6. Officials from three of the five states we interviewed said that the  Alliance for Innovation on Maternal Health (AIM) Initiative had an  immediate or the largest effect on addressing maternal mortality in their  state. Officials from the other two states said they could not identify which  efforts had the largest or most immediate effect on addressing maternal  mortality. Officials from one state noted the importance of a collaborative  approach and the other noted that there is no one contributing factor for  maternal mortality. Some of the HHS-funded efforts previously described  in appendix III had not been awarded at the time of our interviews, such  as the State Maternal Health Innovation Program cooperative  agreements. See table 6 below for information about these states’ efforts.

Appendix VI: GAO Contact and Staff Acknowledgments

Mary Denigan-Macauley, Director, (202) 512-7114 or  deniganmacauleym@gao.gov.

In addition to the contact above, Raymond Sendejas (Assistant Director),  Natalie Herzog (Analyst-in-Charge), Sam Amrhein, Margaret Cullinan,  Kaitlin Dunn, Laura Ann Holland, Diona Martyn, Jennifer Rudisill, and  Vikki Porter made key contributions to this report. Other contributors  include Jieun Chang, Leia Dickerson, Sandra George, and Amy Leone.

Every year in the U.S., hundreds of women die of complications related to pregnancy and childbirth. Mortality varies by race/ethnic group. For example, non-Hispanic black women are more than 3 times as likely to die as non-Hispanic white women, according to the CDC.

This report describes, among other things, Health and Human Services’ ongoing efforts to prevent these deaths. For example, it funds committees in 25 states that comprehensively review maternal mortality and identify ways to prevent it. Officials in the 5 states where we conducted interviews said they were beginning or continuing to address racial/ethnic health differences.