Biruk Abate ^1* Mulat Ayele ¹ Eyob Shitie ¹ Tilahun Wodaynew ¹ Befkad Derese ¹ Molla Azmeraw ¹ Tesfaye Habtie ¹ Muluemebet Kassa ¹ Melesse A. Munie ¹ Dessie Temesgen ¹ Abebe Merchaw ¹ Addis W. Alamaw ¹ Alemu B. Zemariam ¹ Tegene Atamenta ¹ Amare Kassaw ² Ayelign Mengesha ¹ Gizachew Yilak ¹ Mulat Kassa ¹ Gebremeskel Abebe ¹ Muluken C. Agimas ³ Fassikaw Kebede ¹ Molalign A. Adisu ¹ Bogale M. Woreta ¹

• ¹ Woldia University, Woldiya, Ethiopia
• ² Debre Tabor University, Gondar, Amhara, Ethiopia
• ³ University of Gondar, Gondar, Amhara, Ethiopia

Background: Fertility rates are key indicators of population health and demographic change, influencing economic development, healthcare planning, and social policies. Understanding subnational variation in fertility rate is important for effective geographical targeting and policy prioritization. This study aimed to identify geographic variation, trends, and determinants of fertility rates in Ethiopia over the past two decades.We estimated total fertility rates (TFRs) and age-specific fertility rates (ASFRs) using five nationally representative cross-sectional Demographic and Health Surveys collected in Ethiopia between 2000 and 2019. ASFRs represent the number of live births per 1,000 women aged 15 to 49 during the three years before each survey, while TFRs indicate the average number of children a woman would have by the end of her reproductive years, calculated as the sum of ASFRs over five-year intervals. We developed model-based geostatistics by incorporating demographic and healthcare access data with spatial random fields to produce high-resolution fertility rate maps. These results were then aggregated to produce fertility rate estimates at local, sub-national, and national levels in Ethiopia.The national TFR gradually declined from 4.8 live births in 2000 to 4.2 live births in 2019, but it is still above the replacement level of 2.1 children per woman. There were sub-national and local variations in TFR, ranging from 5.7 live births in Somalia and 5.3 Oromia regions to 2.7 live births in Addis Ababa and 3.6 live births Dire Dawa cities. Geographical areas with high TFR were mostly associated with a high proportion of Muslim women and low access to health facilities.Despite a decline in fertility rates among women of reproductive age over the past two decades, marked spatial variation persists at sub-national and local levels in Ethiopia, with demographic factors determining the spatial distribution and rate of decline, highlighting the need for tailored programs and strategies in high-fertility areas to increase access to family planning.