Factors associated with maternal mortality among women with postpartum hemorrhage in the Beni Health Zone, Democratic Republic of Congo: a retrospective cohort study (2022–2025)

Postpartum hemorrhage (PPH) remains the leading direct cause of maternal mortality worldwide, with the greatest burden occurring in sub-Saharan Africa. Evidence on factors associated with maternal death among women with PPH in conflict-affected and resource-limited settings remains limited. This study aimed to identify factors associated with maternal mortality among women with PPH in the Beni Health Zone, Democratic Republic of Congo. We conducted a retrospective cohort study including all women diagnosed with PPH between January 1, 2022, and May 31, 2025, in nine first-level referral health facilities providing comprehensive emergency obstetric care. Because quantitative blood loss was not routinely measured, PPH was identified using standardized clinical and therapeutic criteria documented in medical records, including heavy vaginal bleeding, administration of therapeutic uterotonics, uterine exploration, or blood transfusion. Maternal deaths were classified as PPH-related based on maternal death audit reports and medical record review. Multivariable logistic regression was performed to identify factors independently associated with maternal death, and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were reported. Among 12,340 deliveries, 255 women were diagnosed with PPH, corresponding to a reported incidence of 2.1%. A total of 45 maternal deaths occurred, yielding a case fatality rate of 17.6%. Although an increasing case fatality trend was observed during the study period ( p = 0.0006), this finding should be interpreted cautiously because of the limited observation period and incomplete data for 2025. In the multivariable logistic regression analysis, low educational level (aOR = 2.33; 95% CI 1.05–5.22; p = 0.037), closely spaced pregnancies (< 24 months) (aOR = 3.61; 95% CI 1.55–8.77; p = 0.003), and uterine rupture (aOR = 3.48; 95% CI 1.44–8.52; p = 0.006) were independently associated with maternal death. Maternal mortality among women with PPH remains alarmingly high in this conflict-affected setting. Mortality was independently associated with low educational attainment, closely spaced pregnancies, and uterine rupture. The low reported incidence of PPH likely reflects under-ascertainment related to reliance on clinical rather than quantitative blood loss assessment. Strengthening family planning services, improving access to quality emergency obstetric care, standardizing PPH diagnosis, and addressing health-system barriers—including timely referral and access to blood transfusion—may help reduce PPH-related maternal mortality in resource-limited settings.