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Introduction In China, the increase in high-risk pregnancies along with rising maternal age and complications has underscored the need for the development of maternal and newborn risk management programmes. The Chinese National Maternal and Newborn Safety Action Plan (CNMNSAP) was initiated in 2017. Given that neonatal mortality is a key indicator of healthcare quality, we evaluate the real-world effects of CNMNSAP against neonatal mortality among pregnant women with high-risk conditions.Methods In this retrospective, matched, population-based cohort study, we collected information on all pregnant women with clinically diagnosed conditions from electronic medical records in Chengdu, China, between July 2014 and December 2019. Individual-level data, covering all healthcare services and testing records in public hospitals, were obtained and categorised into two groups based on the timing of CNMNSAP implementation (pre-CNMNSAP vs post-CNMNSAP). After 1:1 propensity score matching, we calculated the annual percentage change (APC) of neonatal mortality within 7 days post-delivery and compared outcomes between two groups of pregnant women with conditions. We then employed multivariate log-binomial regression models to examine the association between the CNMNSAP implementation and temporal changes in neonatal mortality.Results During the 5-year study period, a total of 241 343 women with high-risk conditions delivered prior to CNMNSAP and 163 367 after its implementation. After 1:1 propensity score matching, 299 190 mothers were included for analysis. We estimated that the APC changed from 10.0% (95% CI −0.4% to 21.5%) prior to the maternal risk management programme to −28.5% (95% CI –44.2% to –8.4%) after its implementation, with an attributed risk reduction of 1.29 neonatal deaths per 1000 deliveries annually. In subgroup analysis, we found a significant reduction in neonatal mortality after policy implementation among mothers aged 18–34 years, those with a normal body mass index and those having a history of abortion.Conclusions The CNMNSAP was found to be associated with a significant annual reduction in early neonatal mortality risk among pregnant women with high-risk conditions in Chengdu, China. The maternal risk management programme effectively improved outcomes for high-risk pregnancies, highlighting the importance of maternal risk classification and management throughout pregnancy.