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Background Reducing maternal mortality is one of the key targets of the Sustainable Development Goals (SDGs). In response to the impact of increased birth rate on maternal and child safety following the implementation of the two-child policy in 2013, the Chinese government implemented the risk management strategy (namely Five Strategies for Maternal and Newborn Safety, FSMNS) to reduce maternal mortality ratio (MMR). We aimed to analyze the changes in the proportion of pregnant women at high risk screened before and after the implementation of the risk management strategy and the association with maternal mortality during the two-child policy era in China. Methods We conducted a nationwide longitudinal study using data obtained from the National Statistical Yearbook and the National Health Statistics Yearbook for all 31 provinces from 2008–2017 to assess and analyze the changes in the proportion of pregnant women at high risk screened before (2008–2013) and after (2014–2017) the implementation of the risk management strategy during the two-child policy era. We used generalized estimating equation (GEE) models to analyze the relationship between the proportion of pregnant women at high risk and MMR after controlling for sociodemographic factors, health resources, and other maternal healthcare factors. Results In the past decade, the number of livebirths in China increased by 32.3%, from 13.3 million in 2008 to 17.6 million in 2017. The median proportion of pregnant women at high risk in 31 provinces increased by 64.8%, from 14.87% in 2008 to 24.50% in 2017. The annual rate of increase in the median proportion of pregnant women at high risk after the implementation of risk management (1.33%) was higher than that before the implementation (0.74%). The median MMR in China decreased by 39.6%, from 21.7 per 100,000 livebirths in 2008 to 13.1 per 100,000 livebirths in 2017. The univariate GEE models showed that MMR decreased by 7.9% per year from 2008–2017 (cRR 0.92, 95% CI 0.91–0.93), and the proportion of pregnant women at high risk was negatively correlated with MMR (cRR 0.97, 95%CI 0.94–0.99; p = 0.001). In the multivariate GEE models, after adjusting for confounders, the proportion of pregnant women at high risk remained negatively correlated with MMR. In the subgroup analysis, the association of MMR with GDP per capita and government health expenditure per capita existed only prior to the implementation of risk management; while high MMR was associated with a low proportion of pregnant women at high risk after the implementation of risk management. Conclusion The national risk management strategy contributed to the stable decline of MMR in China during the two-child policy era. Further attention should be focused on pregnant women in China’s central and western regions to ensure reaching SDGs targets and the ‘Healthy China Plan’ by 2030.

Risk management of pregnant women and the associated low maternal mortality from 2008–2017 in China: a national longitude study