I'm not an expert on PDF or typography so i could be wrong here, but I think that this is because FPDF_GetPageWidth() and FPDF_GetPageHeight() give the height and width of the document in points, not pixels. A point is equivalent to 1/72 of an inch.
pdfium_test creates a bitmap that is FPDF_GetPageWidth()xFPDF_GetPageHeight() pixels. So the page is being rendered at fairly low quality. I'm just digging into pdfium myself but it looks like there are some lower level APIs used by the FPDF_ APIs that may give you some more flexibility.