A national cross sectional analysis of obstetric haemorrhage and referral practices among women who died during pregnancy and childbirth in Uganda

Background Obstetric haemorrhage remains the leading cause of maternal mortality in Uganda despite improvements in institutional delivery coverage and implementation of the Maternal and Perinatal Death Surveillance and Response (MPDSR) framework. However, national evidence describing how referral patterns relate to haemorrhage related maternal deaths remains limited. This study examined referral practices among women who died during pregnancy and childbirth in Uganda and assessed factors associated with obstetric haemorrhage as the final cause of death. Methods This retrospective cross-sectional study analysed 2,665 maternal deaths reported nationally between July 2020 and June 2023 using maternal death review data from the District Health Information System 2 (DHIS2) platform. The primary outcome was obstetric haemorrhage as the final cause of death. The main exposure was referral status and level of care from which the woman was referred. Poisson regression with robust standard errors estimated adjusted prevalence ratios controlling for maternal age, parity, marital status, level of care, and duration of stay. Results Obstetric haemorrhage accounted for 48% of maternal deaths. Overall, 63.2% of maternal deaths occurred among referred women, and 62.5% of haemorrhage related deaths involved referral. Women referred from health centres had a higher prevalence of haemorrhage related death than those referred from hospitals (adjusted prevalence ratio 1.55; 95% CI 1.32 to 1.85). High parity ( > = 5) was also associated with haemorrhage related mortality (adjusted prevalence ratio 2.20; 95% CI 1.60 to 3.03). In addition, 42.2% of haemorrhage related deaths occurred within five hours of arrival and delay three was documented in 48.3% of cases. Conclusion Obstetric haemorrhage remains the leading cause of maternal mortality in Uganda and is associated with referral origin and high parity. Strengthening antenatal risk identification, early haemorrhage management at primary facilities, referral coordination, and readiness at comprehensive emergency obstetric care centres is critical for reducing preventable maternal deaths.