BACKGROUND: Despite substantial progress in maternal and neonatal health, Rwanda's mortality rates remain high, necessitating innovative approaches to meet health related Sustainable Development Goals (SDGs). By leveraging data collected from Electronic Medical Records, this study explores the application of machine learning models to predict adverse pregnancy outcomes, thereby improving risk assessment and enhancing care delivery. METHODS: This study utilized retrospective cohort data from the electronic medical record (EMR) system of 25 hospitals in Rwanda from 2020 to 2023. The independent variables included socioeconomic status, health status, reproductive health, and pregnancy-related factors. The outcome variable was a binary composite feature that combined adverse pregnancy outcomes in both the mother and the newborn. Extensive data cleaning was performed, with missing values addressed through various strategies, including the exclusion of variables and instances, imputation techniques using K-Nearest Neighbors and Multiple Imputation by Chained Equations. Data imbalance was managed using a synthetic minority oversampling technique. Six machine learning models-Logistic Regression, Decision Trees, Support Vector Machine, Gradient Boosting, Random Forest, and Multilayer Perceptron-were trained using 10-fold cross-validation and evaluated on an unseen dataset with-70 - 30 training and evaluation splits. RESULTS: Data from 117,069 women across 25 hospitals in Rwanda were analyzed, leading to a final dataset of 32,783 women after removing entries with significant missing values. Among these women, 5,424 (16.5%) experienced adverse pregnancy outcomes. Random Forest and Gradient Boosting Classifiers demonstrated high accuracy and precision. After hyperparameter tuning, the Random Forest model achieved an accuracy of 90.6% and an ROC-AUC score of 0.85, underscoring its effectiveness in predicting adverse outcomes. However, a recall rate of 46.5% suggests challenges in detecting all the adverse cases. Key predictors of adverse outcomes identified in this study included gestational age, number of pregnancies, antenatal care visits, maternal age, vital signs, and delivery methods. CONCLUSIONS: This study recommends enhancing EMR data quality, integrating machine learning into routine practice, and conducting further research to refine predictive models and address evolving pregnancy outcomes. In addition, this study recommends the design of AI-based interventions for high-risk pregnancies. CLINICAL TRIAL NUMBER: Not applicable.