Background <p>Globally, macrosomia affects 3 to 15% of all pregnancies; there is a global variation in the magnitude of macrosomia among countries. It is one of the public health problems in most developing countries and contributes to maternal and newborn complications. There are some inconsistent individual studies done in Ethiopia, but there is no current pooled national data on its prevalence and factors associated with it. So the study will be used to design and implement a well-comprehensive intervention targeting maternal and child health services.</p> Objective <p>To estimate the pooled prevalence and associated factors of fetal macrosomia in Ethiopia.</p> Methods <p>A systematic review and Meta-analysis of published and grey literature was conducted. A Web of Science, EMBASE, PubMed, Scopus, African Journals Online and Elsevier Science direct were searched as electronic databases, while Google Scholar was utilized as a supplementary search engine. Joanna Briggs Institute (JBI) quality appraisal tools were used for quality assessment and the study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to maintain scientific robustness. Statistical analyses were performed using STATA software (version 14). For each identified associated factor, pooled effect sizes, 95% confidence intervals and measures of statistical heterogeneity were calculated. Heterogeneity among the included studies was quantified using I² statistic where a value greater than 50% indicated substantial heterogeneity. Potential sources of heterogeneity were explored using meta-regression, sensitivity analysis, and subgroup analysis. Either random-effects or fixed-effect models were employed based on the observed level of heterogeneity. Potential publication bias was assessed using funnel plots and Egger’s regression test. Statistical significance was declared at a p-value less than 0.05 with a 95% CI.</p> Result <p>A total of 4309 neonates were delivered in Ethiopian Health institutions, from which 3670 singleton births were included to estimate the pooled effect of fetal macrosomia. The pooled prevalence of fetal macrosomia among delivered neonates in Ethiopia was 10.84% (95% CI: 6.38%–15.31%). Regionally, the highest and lowest pooled estimates were reported from Tigray (13.24%) and Amhara region (7.41%) respectively. Significant heterogeneity was observed across the pooled effect (I²= 71.6%, P-value = 0.004) 95% CI. Subgroup analysis by year revealed that the pooled estimate of macrosomia before and after 2019 was 12.31% and 7.42%, respectively. Meta-regression indicated that this heterogeneity was not significantly driven by sample size (<i>p</i> = 0.08), geographic region (SNNP: <i>p</i> = 0.558, Tigray: <i>p</i> = 0.30, Amhara: <i>p</i> = 0.150), or publication year (<i>p</i> = 0.20). Sensitivity analysis was conducted to evaluate individual study effects; the pooled estimate fluctuated between 9.1% and 12.35%, indicating no single study disproportionately influenced the overall result. In the random-effects meta-analysis, five potential determinants were evaluated; however, none demonstrated a statistically significant pooled association due to marked statistical imprecision. The pooled adjusted odds ratios were as follows: Previous history of macrosomia.(AOR = 4.23, 95%CI, 0.334–53.668), being male(AOR = 2.32, 95%CI, 0.40-13.33), physical inactivity (AOR = 3.014, 95%CI, 0.229–39.614), weight gain during pregnancy((AOR = 4.88, 95%CI, 0.169–140.97), and higher gestational age (AOR = 4.71, 95%CI, 0.47–46.28).</p> Conclusion <p>Fetal macrosomia represents a notable public health concern in Ethiopia, with a pooled prevalence exceeding multiple Sub-Saharan regional reports. Because pooled exposure analyses were highly underpowered and statistically non-significant, routine clinical screening during antenatal care should be strengthened, and larger prospective cohort studies are required to establish precise national risk pathways.</p>