BackgroundCardiomyopathy during pregnancy significantly impacts maternal health, contributing to high morbidity and mortality. Identifying risk factors for this condition is crucial for enhancing prenatal care and preventing adverse outcomes. Study designThis population-based case-control study investigates the risk factors associated with cardiomyopathy in pregnant women. MethodsWe analyzed data from 5133 pregnant women (1686 cases with cardiomyopathy and 3447 controls without cardiomyopathy) who received care at healthcare facilities affiliated with Mashhad University of Medical Sciences between March 1, 2017, and June 20, 2024. Risk factors were assessed through logistic regression models, which calculated adjusted odds ratios (AORs) with 95 % confidence intervals (CIs) for various demographic, medical, and pregnancy-related variables. ResultsSignificant risk factors for cardiomyopathy in pregnancy included obesity (AOR = 2.11, 95 % CI: 1.43–2.02), higher education level (AOR = 1.84, 95 % CI: 1.25–1.86), mental health issues (AOR = 2.07, 95 % CI: 1.7–2.5), domestic violence (AOR = 2.02, 95 % CI: 1.08–3.6), twin pregnancy (AOR = 2.6, 95 % CI: 1.57–4.6), and preeclampsia (AOR = 6.9, 95 % CI: 2.78–17.4). Additional risk factors included lack of physical fitness (AOR = 1.5, 95 % CI: 1.13–2.007), history of infectious disease during pregnancy (AOR = 1.4, 95 % CI: 1.11–1.76), anemia (AOR = 1.57, 95 % CI: 1.15–2.09), and hypertension (AOR = 1.55, 95 % CI: 1.18–2.02). Smoking increased risk but was not statistically significant (AOR = 1.29, 95 % CI: 0.69–2.4). ConclusionAddressing modifiable and non-modifiable risk factors in prenatal care is crucial to reducing cardiomyopathy incidence and improving maternal cardiovascular health.