Background: Preterm birth leads to significant neonatal morbidity and mortality. Currently, there are no universal guidance for the ideal method of delivery when managing preterm births. Objective: To determine whether mode of delivery is associated with adverse outcomes in extremely (<28 weeks), very (29–32 weeks) and moderate to late (33-37 weeks) preterm birth. Search strategy and selection criteria: A systematic review and meta-analysis were conducted, including all singleton pregnancies up to 37 weeks. Studies from 2000 to 2025 were included. Data on the most common adverse neonatal outcomes were extracted. Data collection and analysis: 31 studies were included in the meta-analysis, which was conducted using random effects models. The Newcastle-Ottawa Scale was used for qualitative assessment. Results: Mode of delivery was not associated with neonatal mortality at any gestation irrespective of presentation. However, in women with a breech presentation less than 28 weeks, caesarean was associated with a reduction in mortality (OR, 0.30 [95%CI:0.25-0.37]) compared to vaginal delivery. Caesarean delivery below 28 weeks was associated with lower intracranial haemorrhage and higher bronchopulmonary dysplasia rates compared with vaginal delivery (OR, 0.76 [95%CI: 0.59-0.97]) and (OR, 1.56 [95%CI: 1.01-2.39]) respectively. There was an increase in respiratory distress syndrome above 32 weeks in caesarean compared to vaginal delivery (OR, 1.97[95%CI: 1.00-3.88]). Conclusion: There is no indication to undertake caesarean to reduce neonatal mortality in preterm deliveries other than from those with a breech presentation less than 28 weeks. This has important implications for clinical practice.