Studies of determinants of adverse birth outcomes (ABOs) were conducted in Ethiopia; however, there is a lack of a single study considering the factors operating at multiple levels (individual, interpersonal, organisational, environmental and policy levels). Therefore, this study identified combined determinants of ABOs at all levels in Ethiopia by analysing the Demographic and Health Survey data guided by the Ecological model, considering that birth outcomes are shaped by the interaction between a mother’s environment and her biological and psychological health.

This study aims to identify combined determinants of ABOs at all levels in Ethiopia by analysing the Demographic and Health Survey data guided by the Ecological model.

A cross-sectional study design based on interviewer-administered questionnaires was used for the respective Demographic and Health Surveys.

We used data from the 2016 Ethiopian and Demographic Health Survey, a stochastically national representative study with inclusive information on ABOs, to examine how various levels of influence from individual behaviours to environmental-level factors are affecting birth outcomes.

An effective number of 11 023 live births within the 5 years preceding the survey.

ABOs, including low birth weight and preterm birth. Multivariable multilevel mixed-effects logistic regression was used to identify determinants of ABOs through five hierarchical models in Stata V.14. Model I was the null model; models II, III, IV and V sequentially included intrapersonal, interpersonal, organisational and environmental variables, respectively. Statistical significance was determined using ORs with 95% CIs at p

The weighted prevalence of ABOs in Ethiopia is 27.0% (95% CI 25.7% to 28.3%). The final model of the multivariable multilevel mixed-effects logistic regression identified several predictors of ABOs at the intrapersonal or individual level, including maternal age of 15–24 completed years (adjusted OR (AOR)=1.24, 95% CI 1.02 to 1.51); poorest (AOR=1.41, 95% CI 1.01 to 2.00), poorer (AOR=1.42, 95% CI 1.02 to 2.01) and middle wealth quintiles (AOR=1.45, 95% CI 1.02 to 2.06); first-born twin (AOR=2.61, 95% CI 1.31 to 5.21) and second-born twin (AOR=4.05, 95% CI 2.16 to 7.61); and female childbirth (AOR=1.41, 95% CI 1.22 to 1.63). On the other hand, intimate partner physical violence (AOR=1.19, 95% CI 1.07 to 1.34) was the only factor associated with ABOs at the interpersonal level; cluster altitudes of 180–1500 m (AOR=1.28, 95% CI 1.05 to 1.55) and 2501–3455 m (AOR=1.51, 95% CI 1.15 to 1.99) were found to be an exposure of ABOs at the environmental level.

The prevalence of ABOs in Ethiopia is high. Factors associated with ABOs at the individual level include maternal age, wealth quintile, twin birth and female birth. In contrast, exposure variables at the interpersonal level comprise intimate partner violence, and those at the environmental level include cluster altitude. To improve ABOs and consequently reduce neonatal mortality, maternal and child health investment and future studies should act at all levels.