Background Both individual- and aggregate-level studies have yielded inconsistent results about the association between caesarean birth and neonatal mortality. We provide an interpretation of the changing association over time between caesarean birth and neonatal death using Demographic and Health Survey (DHS) data within the context of Ethiopia.

Methods We used data from Ethiopian DHS in 2000, 2005, 2011, and 2016. We analysed the association between caesarean birth and neonatal death using log-Poisson regression models for each survey adjusted for potential confounders. We then applied the ‘Three Delays Model’ to provide an interpretation of the changing association between caesarean birth and neonatal death in Ethiopia.

Results The adjusted prevalence ratios (aPR) for neonatal death among neonates born via caesarean section versus vaginal birth increased over time, from 0·95 (95% CI, 0·29, 3·19) in 2000 to 2·81 (95% CI, 1·11, 7·13) in 2016. The association between caesarean birth and neonatal death was stronger among rural women (aPR (95% CI) 3·43 (1·22, 9·67)) and among women from the lowest quintile of household wealth (aPR (95% CI) 7·01 (0·92, 53·36)) in 2016. However, the aggregate-level analysis revealed that an increase in caesarean section rate is correlated with a decrease in the proportion of neonatal deaths.

Conclusion The naïve interpretation of the changing association between caesarean birth and neonatal death from 2000 to 2016 is that caesarean section is increasingly associated with neonatal death. However, the changing association reflects improvements in health service coverage and a shift in the characteristics of Ethiopian women undergoing caesarean section after complicated labour or severe foetal compromise.