The present study investigated the prevalence of EBF in 77 districts that conducted the LQAS survey in 2021 and 2022. EBF is a globally recommended practice that aims at not only improving infant and young child nutrition but also providing additional benefits to the mother and child [1,2,3]. The present study findings showed that 62.3% of children under 6 months were exclusively breastfed. The child’s age, mother’s age and residence were the sociodemographic factors associated with EBF. Older mothers and mothers living in rural areas were more likely to exclusively breastfeed their children. Among the health-related factors, mothers who had attended ANC during the pregnancy of the child were more likely to exclusively breastfeed while children who had received Vitamin A supplementation were less likely to be exclusively breastfed.

The proportion of EBF observed by this study is comparable to the average observed by the 2016 Uganda Demographic and Health Survey (UDHS) (63%) more than seven years ago [7]. It is therefore likely that there have not been any significant gains in increasing the prevalence of EBF in the majority of the distrcits over the past 20 years in Uganda. Although the observed rate was still higher than most countries in Africa and globally [5], attaining greater improvements in EBF could play a vital role in preventing chronic childhood undernutrition in the country [7, 10, 11, 17]. Moreover, that older mothers were more likely to exclusively breastfeed compared to teenage mothers was like the observation made by researchers in Ethiopia [21]. Unlike teenage mothers, older mothers may have more experience and knowledge about the benefits of EBF due to previous pregnancies and motherhood. This awareness can influence their decision to breastfeed exclusively [29, 30]. Besides, older mothers may have more stable socioeconomic circumstances, which can positively impact their ability to exclusively breastfeed [13]. Understanding and addressing the causes of lower EBF rates among teenage mothers could accelerate national efforts towards improving EBF. This is particularly notable since about quarter of teenage girls in Uganda, have begun their motherhood journey, among them, 19% have already given birth, and 5% are expecting their first child [7].

Moreover, the study findings showed that mothers living in rural areas were more likely to exclusively breastfeed. Although this is unlike findings in Southwest Ethiopia [19], rural-urban gaps in breastfeeding studied in Lao highlight much lower rates among urban mothers [20]. Moreover, still unlike findings in Southwest Ethiopia [19], other studies have found that higher education among women which is common in urban women was linked to lower rates of EBF rates [31, 32]. This could be attributed to a disparity in workplace dynamics, incomes and access to breastmilk substitutes which are some of the reasons attributed to lower rates of EBF in urban areas [13, 20]. An integrated approach that supports the education and employment of women and additionally incorporates the demands of motherhood must be explored [13]. Otherwise, Uganda will persist in facing challenges related to lower EBF rates among urban mothers, contributing to a state of overall stagnation for almost a decade [7].

On the other hand, in agreement with the findings of the study in Southwest Ethiopia [19] mentioned earlier and other studies [13, 33], ANC attendance was linked to a higher likelihood of exclusively breastfeeding. ANC is an opportunity to provide education and counselling on not only EBF but also other proper infant feeding practices [19, 33, 34]. Therefore, this study underscores the importance of ANC attendance in fostering proper infant and young child nutrition practices. However, ANC attendance must be complemented by other desired health-seeking behavior such as institutional birth delivery which although not observed by this study is a studied predictor of EBF [33]. Consequently, such factors may work in tandem to foster higher rates of EBF. Moreover, consideration needs to be made for the number of times a mother attended which also predicts EBF rates [13, 19]. This is possibly because various information may be shared during the different contact visits and a mother who attended fewer visits may miss some information. The current study, however, found no significant association between the number of ANC visits and EBF.

In this study, children who had received Vitamin A supplementation were less likely to be exclusively breastfed. Typically, according to WHO recommendations, Vitamin A supplementation is advised to commence at 6 months of age [35]. This aligns with the cessation of the duration of EBF. However, when an infant under 6 months of age is not exclusively breastfed, the WHO additionally suggests Vitamin A supplementation, but not as a strong public health intervention [36]. This is due to the current evidence being less definitive, and the balance between benefits and risks being less certain. Considering the limitations of the present study, the rationale for Vitamin A supplementation in children under 6 months might be rooted in the need to assess the risk of morbidity or mortality, a question for which the available data were insufficient to provide a conclusive answer. As a result, it is somewhat surprising that some children under 6 months received Vitamin A supplementation. On the positive side, this practice may provide some breastmilk-like benefits to these non-exclusively breastfed infants, such as immune support [35, 36]. Nevertheless, it remains uncertain whether health workers administered Vitamin A based on EBF status, if Vitamin A was provided without considering the infant’s age, or if the recollection of events played a role. This ambiguity could serve as a potential avenue for future research.

This study was a secondary analysis of data from the district-based 2021 and 2022 LQAS surveys that covered more than half of the districts (77) in Uganda to present the most current findings on EBF. It benefited from its remarkable sample size that was representative of districts giving reliable estimates and robust coverage unlike similar studies in the country [13]. However, it is essential to acknowledge certain limitations inherent in the study. Firstly, the use of cross-sectional LQAS surveys, which rely on reported data regarding EBF practices, exposes the research to the inherent constraints of cross-sectional research designs and potential social desirability bias [37, 38]. For instance, this study assessed EBF among a combined sample of children 0–6 months at a point in time. However, EBF practices might vary over time, with some mothers practising it intermittently, making it challenging to precisely determine EBF although it was a, straightforward method ( reporting EBF rates for the 24 hours before the survey). As a result, the actual EBF rates could potentially be much lower. Future LQAS surveys may need to consider collecting EBF since birth to establish an even more reliable estimate. Additionally, although the researchers carefully studied variable selection for the study using the UNICEF Conceptual Framework on Maternal and Child Nutrition [14], it is important to note that this study was limited by its inability to consider certain factors due to data availability constraints.