African Journal Of Public Health And Health Systems
AJOPHA | | Open Access | Peer-Reviewed | Pan-African Research Journals (PARJ) DOI: 10.XXXXX/ajopha.2025.XXXXX | Received: January 202 6 | Accepted: February 20 26 | Published: March 2025 Infant and Young Child Feeding Practices Among Mothers with Children Below 24 Months in Ikotos County, Eastern Equatoria, South Sudan: A Community-Based Cross-Sectional Study Lemi Robert Albert ¹ ¹ Faculty of Health Sciences, Uganda Christian University, Mukono, Uganda Correspondence: lemi.loremo85@gmail.com | ORCID: 0000-0000-0000-0000
Introduction
Infant and Young Child Feeding (IYCF) practices are among the most powerful determinants of child survival, growth, and cognitive development. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) jointly recommend a continuum of feeding practices spanning the first 1,000 days of life: initiation of breastfeeding within one hour of birth, exclusive breastfeeding (EBF) for the first six months, introduction of safe and nutritionally adequate complementary foods at six months, and continued breastfeeding up to 24 months and beyond (WHO & UNICEF, 2003). These evidence-based recommendations have been shown to prevent a substantial proportion of under-five deaths and to safeguard children from malnutrition-related diseases (Jones et al., 2003; UNICEF, 2005). Despite decades of advocacy, inappropriate IYCF practices remain pervasive across low-income countries, particularly in sub-Saharan Africa. UNICEF (2005) reported that less than one-third of children under six months of age in sub-Saharan Africa were exclusively breastfed, and fewer than 20% of children aged six months received appropriately diverse complementary foods. The Lancet Nutrition Series (2009) estimated that suboptimal breastfeeding alone accounted for over 800,000 child deaths annually, while inappropriate complementary feeding contributed to widespread stunting, wasting, and micronutrient deficiencies. South Sudan presents a particularly acute case. Classified as one of the 33 countries globally with sub-optimal IYCF practices (IBFAN, 2010), the country endures a triple burden of food insecurity, ongoing armed conflict, and fragile health systems. According to the UNICEF South Sudan nutrition brief (2019), only 15% of children aged 6–23 months received the minimum dietary diversity, and a mere 5% achieved the minimum acceptable diet. The global acute malnutrition (GAM) rate in Ikotos County stood at 13.5% exceeding the WHO emergency threshold of 10% (Health Link South Sudan, 2018; WHO, 2009). Despite the South Sudan government's development of the MIYCN Policy Guideline, implementation at the community level in remote counties like Ikotos remains critically limited. A review of existing literature reveals a near-total absence of community-based IYCF data from Ikotos County. The two published South Sudan studies by J. Bruno et al. (2018) on delayed breastfeeding initiation in Juba Teaching Hospital, and E.B. Warille et al. (2017) on EBF knowledge in Al Sabah Children's Hospital were both facility-based, limiting their applicability to rural community settings. This study was therefore designed to fill this critical knowledge gap by comprehensively describing IYCF practices among mothers and caregivers of children below 24 months in Ikotos County.
Study Objectives
The specific objective addressed in this paper is: • To determine the Infant and Young Child Feeding practices among mothers with children below 24 months in Ikotos County, Eastern Equatoria, South Sudan.
Conceptual Framework
The study was grounded in a conceptual framework (Figure 5) that situates IYCF practices at the intersection of sociodemographic determinants (maternal age, education, marital status, occupation, income source), child and paternal characteristics, healthcare access, and moderating cultural and religious variables. These independent and moderating factors interact to shape four core IYCF outcomes: early breastfeeding initiation, exclusive breastfeeding, complementary feeding, and continued breastfeeding which in turn determine child nutritional status, morbidity, and mortality.
Global And Regional Context Of Iycf Practices
Globally, sub-optimal IYCF practices persist as a leading contributor to child undernutrition. WHO (2009, 2019) and Caetano et al. (2010) documented that delayed breastfeeding initiation, prelacteal feeding, and both early and late introduction of complementary foods remain the most common departures from optimal practice. In developing countries, these behaviours are compounded by cultural beliefs, low maternal education, poverty, and insufficient health system support (Kumar et al., 2009). WHO (2014) reported a global daily death toll of 17,000 children under five, with over 70% of under-five deaths occurring in Africa and East Asia. Jones et al. (2003) ranked exclusive breastfeeding and continued breastfeeding among the top child survival interventions globally. IBFAN (2014) estimated that optimal exclusive breastfeeding could prevent 1.4 million under-five deaths annually worldwide.
Breastfeeding Initiation
Early initiation of breastfeeding defined as putting the newborn to the breast within one hour of birth is critical for neonatal survival. Linkages Project (2004) established that colostrum, the thick yellowish early breast milk produced in the first days postpartum, provides passive immunological protection against neonatal infections. A study in rural Ghana (Kumar et al., 2006) demonstrated that initiation within the first hour of birth could prevent 22% of neonatal deaths; initiation within the first day reduced deaths by 16%. The Nigeria Demographic Health Survey (2013) reported that 59% of mothers offered prelacteal feeds to their newborns, a practice associated with delayed lactation onset and increased infection risk (UNICEF, 2017).
Exclusive Breastfeeding
Exclusive breastfeeding defined as provision of breast milk only, with no other liquids or solids except prescribed medications for the first six months of life is the single most effective nutritional intervention for infant health. Zenebu et al. (2014) in Ethiopia found that while 93.8% of caregivers were knowledgeable about EBF, only 82.2% actually practised it, illustrating the persistent knowledge-practice gap. In India, EBF prevalence stood at 48%, with minimum dietary diversity at 27.4% and minimum meal frequency at 29% among children aged 6–23 months. Ethiopia's DHS (2016) reported EBF at 58% nationally, while the 2011 DHS found early initiation at only 38% in Amhara region.
Complementary Feeding
Complementary feeding the provision of safe, adequate, and age-appropriate solid or semi-solid foods beginning at six months bridges the growing nutritional gap between breast milk and a child's escalating energy and micronutrient requirements (WHO, 2003). SCN (2003) emphasized that the frequency of complementary feeding must be adapted to the child's gastric capacity: at least twice daily for breastfed infants aged 6–8 months, three times for those aged 9–23 months, and four times for non-breastfed children. Studies across Africa consistently document early introduction of complementary foods as the norm rather than the exception. A study by Olwedo et al. (2008) in an IDP camp in northern Uganda found that 38.8% of children under six months had been introduced to complementary foods. In Kenya, Kimathi et al. (2010) found that complementary foods were introduced too early despite two-thirds of mothers being aware of WHO timing recommendations. Gewa et al. (2015) in Ghana attributed high stunting prevalence in children aged 12–24 months to both late complementary food introduction and inadequate dietary diversity.
Iycf In The South Sudanese Context
South Sudan's protracted conflict since its independence in 2011 has severely disrupted household food security, health infrastructure, and child care capacities. According to UNICEF (2016), South Sudan data showed that only 55% of children were initiated to breastfeeding within one hour of birth, 5% of children under six months were exclusively breastfed, 18% received prelacteal feeds, and 17% of children aged 6–9 months did not receive complementary semi-solid foods. These figures underscore the urgent need for community-based IYCF research in conflict-affected settings like Ikotos County, where no such data previously existed.
Study Design And Setting
A community-based, cross-sectional study employing quantitative methods was conducted in Ikotos County, Eastern Equatoria State, Republic of South Sudan, in March 2020. Ikotos County lies at coordinates 4°4'42"N, 33°6'32"E and shares borders with Magwi County to the West, Torit County to the North, and Budi County to the East. Eastern Equatoria borders Uganda to the south, Kenya to the southeast, and Ethiopia to the northeast. The county is subdivided into six payams (sub-county equivalents) Ikotos Central, Lomohidang South, Lomohidang North, Losite, Hatire, and Imotong containing 33 bomas (parishes) and 154 villages. Ikotos is home to approximately 35,319 people (SSRC, 2019), predominantly agro-pastoralist communities speaking Langi, Dongotono, and Lotuho languages. The healthcare infrastructure comprises nine facilities including St. Theresa Mission Hospital and eight Primary Health Care Centres and Units (PHCCs/PHCUs). The choice of a cross-sectional design was justified by its efficiency in describing the prevalence of IYCF practices and associated factors at a defined point in time, and by its suitability for generating baseline data in settings with no prior community IYCF studies.
Population And Sample Size
The target population comprised 2,532 mothers or caregivers with children below 24 months residing in Ikotos County (SSRC, 2019). The accessible population was 1,279 mothers from the 12 selected villages. The study population was 317 mothers who met the inclusion criteria and formally consented to participate. Sample size was calculated using the Kish-Leslie formula (Wayne et al., 1997):
Where Z = 1.96 (95% confidence interval), P = 0.75 (prevalence of EBF in South Sudan per GoSS MIYCN Strategy 2009–2012), and d = 0.05 (margin of error). Substituting:
A 10% non-response adjustment was added per Magnani (1997): 0.10 × 288 = 28.8 ≈ 29 additional respondents, yielding a final sample of \(n = 317\).
Sampling Procedure
A multi-stage sampling approach was employed. First, Ikotos County was selected from five Eastern Equatoria counties using simple random sampling (draw without replacement). Second, four of the six payams Ikotos Central (\(n=80)\), Losite (\(n=79)\), Lomohidang North (\(n=79)\), and Lomohidang South (\(n=79)\) were randomly selected. Third, three villages per payam (12 villages total) were randomly drawn. Finally, within each village, mothers were identified using village health worker registers and selected through systematic random sampling with a calculated sampling interval. Inclusion criteria required mothers or caregivers aged ≥18 years with children below 24 months who had resided in Ikotos for at least 24 months and who gave informed consent. Very sick mothers and those who did not meet inclusion criteria were excluded. Where multiple eligible mothers resided in one household, the mother with the youngest child was selected.
Data Collection And Management
A structured questionnaire, developed per the specific objectives and validated by subject matter experts, was used to collect primary data through face-to-face interviews. The tool was pre-tested on 10 mothers and translated into Langi language to ensure linguistic accessibility. Five trained research assistants fluent in both Langi and English conducted 30-minute interviews at respondents' homes. Data quality was assured through daily field editing by the principal investigator, test-retest reliability assessment, and double entry verification in Microsoft Excel before export to SPSS version 21.
Data Analysis
Descriptive statistics (frequencies, percentages, means, medians, and standard deviations) summarised participant characteristics. Graphical representations including bar charts and pie charts were used to depict IYCF practice distributions. All analyses were performed at a 95% confidence interval. Ethical clearance was obtained from the Uganda Christian University Research and Ethics Committee, with additional permissions from the Ikotos County Health Officer. Informed consent was obtained from all participants in their preferred language.
Sociodemographic Characteristics Of Respondents
A total of 317 mothers or caregivers of children below 24 months participated in the study, yielding a 100% response rate. Table 1 presents the sociodemographic profile of participants.
Variable
Percentage (%) Age of Mother (Years) 18–23 years 88 27.8 24–29 years 118 37.2 30–34 years 66 20.8
45 14.2 Marital Status Married 253 79.8 Single 56 17.7 Divorced 8 2.5 Maternal Education Level No Formal Education 159 50.2 Primary Education 114 36.0 Secondary Education 44 13.8 Maternal Occupation Housewife 109 34.4 Informal Employment 149 47.0 Formal Employment 59 18.6 Place of Delivery Home 67 21.1 Primary Health Care Centre 195 61.5 Hospital 55 17.4 Head of Household Male 255 80.4 Female 62 19.6 Sex of Child Male 135 42.6 Female 182 57.4 Age of Child (Months) 0–6 months 212 66.9 >6–24 months 105 33.1 Primary Caregiver Both Biological Parents 187 59.0 Mother Only 130 41.0
The majority of respondents (37.2%, \(n=118)\) were aged 24–29 years, while only 14.2% (\(n=45)\) were aged 35 years or above. Most participants were married (79.8%, \(n=253)\). Half of all mothers (50.2%, \(n=159)\) had no formal education, and 36.0% had completed primary schooling. Informal employment was the most common occupation (47.0%, \(n=149)\). Female children constituted 57.4% (\(n=182)\) of the study group. Male-headed households dominated at 80.4% (\(n=255)\), and 59.0% of children were cared for by both biological parents.
Infant And Young Child Feeding Practices
IYCF Variable Frequency Percentage (%) Early Breastfeeding Initiation (within 1 hour) Yes Initiated within 1 hour 111 35.0 No Delayed initiation 206 65.0
After 2 hours 25 12.1 After 24 hours 128 62.1 After >24 hours 53 25.8 Prelacteal Feeds Administered Yes Prelacteal feeds given 142 44.8 No No prelacteal feeds 175 55.2
Exclusively Breastfed 238 75.0 Not Exclusively Breastfed 79 25.0 Breastfeeding Frequency (last 24 hours) 4 times per day 119 37.5 5–9 times per day 85 26.8 10–14 times per day 72 22.7 >14 times On demand 12 13.0 Age at Introduction of Complementary Feeding Before 6 months 187 58.9 At 6 months (recommended) 92
*
After 6 months 38 19.1 Continued Breastfeeding Duration Stopped at 6 months 75 23.6 7–12 months 67 21.3 13–18 months 32 10.1 >18 months 143 45.0 Note. * Indicates WHO-recommended practice. Data source: Primary data, Ikotos County, March 2020.