Risk factors for postpartum haemorrhage recorded in primary care electronic health records in north eastern Iran: a population-based case control study

Every year, a significant number of mothers die from bleeding after giving birth, a condition known as postpartum haemorrhage. This remains the leading cause of maternal death globally, accounting for more than a quarter of all such fatalities. Because the risk of this bleeding can be unpredictable, health organizations have long relied on identifying women who are likely to be at higher risk. These risk factors include things like carrying more than one baby, having a large baby, or having certain pregnancy complications. By spotting these signs early, doctors can prepare better, choose the safest place for delivery, and act quickly if bleeding starts. However, most of what we know about these risks comes from hospital records where blood loss is measured directly. In many parts of the world, especially in middle-income countries, the story of a pregnancy is often kept in community health records long before a woman ever reaches a hospital. It is unclear how well these community records capture the truth about bleeding, or if the risk factors we trust in hospitals tell the same story in a village clinic.

A team of researchers in north-eastern Iran decided to investigate this gap by looking at a massive digital archive of health records. They focused on the Sina electronic health record system, which covers the primary care network for Mashhad and its surrounding counties. This system tracks the health of families, recording everything from prenatal check-ups to post-birth care. The researchers wanted to see if they could find the same risk factors for bleeding in these community records that are known to exist in hospitals. They examined data from over 270,000 births that occurred between October 2017 and September 2024. In this vast dataset, they identified nearly 5,000 women who had a record of postpartum haemorrhage and compared them with hundreds of thousands of women who did not. Their goal was to see if things like a mother's age, her education, her weight, or where she lived could predict who would be recorded as having bled excessively.

The results revealed a picture that was far more complex than a simple list of medical risks. The researchers found that the recorded rate of bleeding varied wildly depending on where a woman lived. In the rural areas, the recorded rate was very low, at just 0.60 percent. In the city of Mashhad, it was much higher, reaching 3.71 percent. When the researchers looked at the medical factors usually associated with bleeding, such as anaemia (low iron), a large baby, or a specific type of placenta problem, they found almost no connection in these records. Women with these known risks were not more likely to have a record of bleeding than women without them. This was surprising because medical textbooks and hospital studies consistently show these factors increase the danger.

Instead of medical conditions, the strongest signals in the data were about where and how the birth happened. Women who gave birth outside of a hospital were significantly more likely to have a record of bleeding. Similarly, women carrying twins or triplets were more likely to be flagged. The researchers also noticed that women with university degrees and those living in the city were more likely to have a record of bleeding than those with less education or those in rural areas. This pattern held true even when comparing women within the same local health network. The data suggested that the record of bleeding was not necessarily a perfect reflection of how much blood was lost, but rather a reflection of how carefully the event was documented and reported.

The study concluded that the electronic records in this region were likely missing a great deal of information. The wide differences between health centers, with some recording no bleeding at all and others recording it frequently, pointed to inconsistent documentation practices rather than real differences in how often women bled. The fact that known medical risks like anaemia or a large baby did not show up as predictors suggested that the records were incomplete. If the data were capturing the true medical reality, these well-known risks would have stood out clearly. The researchers found that the location of the health center and the year of birth were better at predicting who appeared in the bleeding records than any of the mother's health characteristics.

This does not mean that bleeding is not a serious problem in these communities, but it does mean that the current digital records cannot be trusted to identify who is at risk. The study highlights that relying on these records to predict danger or to compare the performance of different clinics would be misleading. The researchers emphasized that to truly understand and prevent postpartum bleeding, health systems need to ensure that blood loss is measured objectively at the time of birth and that this information is reliably transferred from the hospital back to the community health records. Until that link is solid, the digital maps of risk in these regions remain incomplete, showing us more about who was seen and recorded than about who actually bled.