Objectives <p>This research aimed to estimate the occurrence of high-risk pregnancies and examine their correlation with maternal and neonatal outcomes among women in Northwestern China.</p> Methods <p>A retrospective cohort study involved pregnant women who gave birth at Ningxia Medical University General Hospital, Northwestern China, between March and October 2023. All eligible participants were included. A self-administered questionnaire was given to pregnant women to gather information on pregnancy risk factors at the time of booking (the first antenatal visit) and evaluated using the color coding risk assessment tool to classify high-risk pregnancy status (yes/no). Maternal and neonatal outcomes were obtained from the hospital data. Simple and multiple logistic regression analyses were conducted to model the relationship between high-risk pregnancy status with maternal and neonatal outcomes.</p> Results <p>Overall, 1211 pregnant women were enrolled, and 567 (46.8%) women had high-risk pregnancies. A multivariate analysis showed that high-risk pregnant women had significantly greater odds of adverse outcomes (AOR = 1.575, 95% CI 1.253–1.979).</p> Conclusion <p>Nearly half of the women in Ningxia, China, were detected as having high-risk pregnancies at first antenatal appointment, and this status was significantly associated with adverse maternal and neonatal outcomes. This recent data-driven study highlights the scientific validation, continued relevance and importance of reinforcing color coding in maternal care.</p>