Objective: The aim of this study was to assess the effect of maternal undernutrition on adverse birth outcomes in Gedeo zone public hospitals. Design: A prospective cohort study was employed Setting: Gedeo zone public hospitals Population: Antenatal care women Method: A modified Poisson regression model with robust standard errors was used to determine relative risk and the statistical association was declared at the p-value ≤0.05. Main outcome measures: Risk of obstetrics and birth outcomes from undernutrition during pregnancy. Result: The incidence of the adverse obstetrics outcomes among women with undernourishment were hypertensive disorder during pregnancy 22.78%, antepartum haemorrhage 6.33%, obstructed labor 4.64%, premature rupture of the membrane 8.0%, preterm labor 19.83%, instrumental vaginal delivery 5.49%, operative delivery 18.14%, postpartum haemorrhage 18.14%, and sepsis or chorioaminitis 11.9%. Similarly the incidence of stillbirth 34(4.71%), intrauterine growth restriction (IUGR) 72(10%), small for gestational age (SGA) 70(9.7%), low birth weight (<2500g) and preterm birth 91(12.62%) and 118 (16.36%), low first minute Apgar score (<7) 230(32.0%) and low fifth minute Apgar score was and 130 (18.0%), birth asphyxia 136 (18.86%), neonatal intensive care unit (NICU) 108 (15.0%), neonatal death of 26.3/1000 live birth. The risk of hypertensive disorder during pregnancy (HDDP) was (aRR)=4.07, 95%CI: 2.53-6.55), antepartum haemorrhage (APH) (aRR=5.0, 95%CI:2.08-12.72), preterm labor (aRR=1.8, 95%CI: 1.23-2.62), operative delivery (aRR=1.24,95%CI;0.87-1.78), postpartum haemorrhage (aRR=3.02, 95%CI: 1.91-4.79), and sepsis/chrioaminitis (aRR=3.55, 95%CI: 1.83- 6.89) times higher compared to women without undernourishment. The risk of intrauterine growth restriction (IUGR) aRR=4.05 times (95%CI; 2.87-8.47), small for gestational age (SGA) aRR=2.49 times (95%CI; 1.55-4.0), birth asphyxia aRR=2.72 times (95%CI; 2.0-3.0), and admission to neonatal intensive care unit (NICU) aRR=4.29times (95%CI; 2.94-6.24) higher for undernourished women than normally nourished women. Conclusion: According to this study, the overall incidence of adverse birth outcomes was high. The fetus born from an undernourished woman has a higher risk for stillbirth 1.92 times, intrauterine growth restriction 4.05 times, small for gestational age 2.49 times, birth asphyxia 2.72 times, admission to NICU 4.29 times, and early neonatal death 3.79 times.