Breastfeeding is a cornerstone of child health, offering essential nutrients and immune system support for optimal growth and development (1). Breast milk provides bioactive nutrients and antibodies that bolster a child's immune system and growth (2, 3), promote growth, and facilitate tissue repair (3). Breastfeeding also contributes to preventing infectious diseases, gastroenteritis, respiratory disease, childhood diabetes, obesity, and dental disease in children (4). It positively affects the intelligence quotient (IQ) and educational and behavioral outcomes of children (5). Breastfeeding mothers benefit from decreased risks of breast and ovarian cancer and diabetes (6). Compared with non-breastfed children, breastfed children have a reduced risk of acute and chronic illness and improved cognitive outcomes (5), resulting in greater educational achievement and earning potential. Hence, breastfeeding is a critical component of infant and child health, even for mothers (7). The World Health Organization and UNICEF recommend starting breastfeeding within an hour of birth, exclusively nursing for the first 6 months, and continuing breastfeeding for at least 2 years (8) However, challenges persist, particularly in ensuring consistent and equitable breastfeeding, early breastfeeding initiation, exclusive breastfeeding and predominant breastfeeding (9). Exclusive breastfeeding refers to infants receiving only breast milk with no other liquids or solids, while predominant breastfeeding means breast milk is the primary source of nutrition for infants under 6 months (10, 11). Disparities have continued for these practices despite global, national, and local efforts and interventions (12, 13).

For the last five decades, Ethiopia has actively promoted optimal breastfeeding practices (13–17). This dedication reflects a long-standing national commitment to improving child health. Improved access to and use of healthcare has contributed to a rapid decline in under-five mortality rates in Ethiopia (18). A recent study found that the prevalence of under-five mortality in the country was 5.9% (59 deaths per 1,000 live births) (19). This represents significant progress in addressing child health challenges in Ethiopia. The roots of this focus likely lie in the late 1970s and 1980s (20). During this period, a global movement to improve infant and young child feeding practices, including breastfeeding promotion, gained momentum. Ethiopia, which is a significant challenge with respect to childhood mortality rates, highlights the well-documented health benefits of breastfeeding as a potential solution (13–17). This recognition likely sets the stage for the ongoing national commitment to promoting these practices reflected in various national policies and strategies (9, 21, 22). The National Strategy for Infant and Young Child Feeding in Ethiopia aims to improve children's health through better feeding practices (21). It sets national standards for breastfeeding and complementary feeding, emphasizing early breastfeeding initiation and exclusive and predominant breastfeeding for the first 6 months. The National Adolescents, Maternal, Infant, and Young Child Nutrition Guideline (2016–2020) is another policy document in Ethiopia focused on improving nutrition, including breastfeeding (9). Recently, the National Infant and Young Child Feeding in Emergency (IYCF-E) guidelines were released, providing practical guidance for ensuring appropriate infant and young child feeding in emergency response (22).

Multiple factors influence breastfeeding practices beyond a mother's control (12). Exclusive and predominant breastfeeding at the population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings (1). Such interventions must be guided by research findings for well-informed policies, strategies and initiatives. One such approach is the World Health Organization (WHO) and UNICEF's Baby-Friendly Hospital Initiative (BFHI), which promotes optimal breastfeeding practices by encouraging facilities to implement the Ten Steps to Successful Breastfeeding (23). Ethiopia is implementing the Baby-Friendly Hospital Initiative (BFHI) as part of its multisector National Nutrition Programs to improve child nutrition (8, 24). While positive developments in tackling malnutrition have occurred over the last 10 years, the initial levels were so severe that the country required substantial investment in nutritional programs (24).

Ethiopia's diverse sociocultural landscape and variations in healthcare access necessitate a nuanced examination of exclusive and predominant breastfeeding (24). The country has made notable strides in terms of maternal and child health (25). For instance, the Under-five mortality in Ethiopia decreased by 60% from 2000 to 2016, falling from 166 to 67 deaths per 1,000 live births (19). While previous studies have explored exclusive and predominant breastfeeding, a comprehensive analysis of time trends and determinants over an extended period, mainly using EDHS data in the Ethiopian context, remains limited (9, 15, 16, 26, 27). As far as the researcher knowledge, there has been no recent study on time series data to understand trends in exclusive and predominant breastfeeding practices. Previous studies have been fragmented, and there is a paucity of holistic evidence on the extent of the impacts of policy and implementation strategies. This lack of clarity is particularly concerning when considering potential disparities in exclusive and predominant breastfeeding across different regions and sociodemographic groups within the country. Investigating prevalence trends and disparities will offer insights into the effectiveness of interventions and guide the development of targeted strategies to improve exclusive and predominant breastfeeding practices. It is also crucial for policymakers, healthcare providers, and organizations working to improve child health in Ethiopia.

This study analyzed data from five Ethiopian demographic and health surveys (EDHSs) (2000–2019) (28–32). Therefore, this study aims to fill this gap by examining time trends, and determinants of exclusive and predominant breastfeeding practices (<6 months) across regions and urban/rural areas over the past two decades.

In the present study, children aged <6 months and their mothers were distributed unevenly across the majority of sociodemographic characteristics, implying that these factors are likely associated with exclusive and predominant breastfeeding practices. The number of home births in Ethiopia has shown a positive trend, declining significantly from 88.20% in 2000 to 45.23% in 2019, implying increased literacy and improved access to and utilization of maternal healthcare services, as depicted in other studies (33, 34). Similarly, the decline in the proportion of mothers who did not utilize antenatal care (ANC) from 67.64% in 2000 to 26.17% in 2019 is a positive development, as other studies confirmed that the utilization of maternal healthcare services in Ethiopia is improving (16, 35). However, a significant concern is that most mothers do not utilize postnatal care. Most of the mothers and their children in Ethiopia lived in families of five or more members.

The WHO and UNICEF recommend that children should only receive breast milk for the first 6 months of life (exclusive breastfeeding) or that they may also receive small amounts of water, oral rehydration solutions (ORSs), or medicines (predominantly breastfeeding) (36, 37). This nationwide population-based study investigated exclusive and predominant breastfeeding practices over the last two decades, indicating the impact of policies and strategies (9, 21, 22). Previous studies were fragmented and focused on specific populations and timeframes, hindering a complete understanding of national prevalence trends through time and disparities (9). The time series analysis revealed that the trends of exclusive and predominant breastfeeding in Ethiopia were inconsistent and fluctuated across different regions over the last 20 years.

The observed trend in exclusive breastfeeding rates—an increase from 2000 to 2016 followed by a decline in 2019—is a complex issue with multiple potential causes (Figure 2). These findings align with a previous study on breastfeeding practices, particularly, showing a decline in ever-breastfeeding and inconsistent trends in early initiation (38). The possible reasons might be demographic changes, dietary pattern changes and an increase in access to formula milk. Another possible explanation might be that public health interventions might have declined in intensity or quality after 2016, which could have contributed to the subsequent drop in exclusive or predominant breastfeeding practices (21, 39). However, predominant breastfeeding declined from 2000 to 2016 and subsequently increased in 2019. The study revealed no significant associations between these rates and the year of the survey, despite these fluctuations suggesting that these breastfeeding practices are not improving. These findings contrast with a study that concluded that breastfeeding practices improved in LMICs over the past decade despite regional variation (40). A possible explanation might be reflected in dietary pattern changes, increased access to formula milk, and demographic changes in recent years.

Except for the Gambella regional state of Ethiopia, which showed a different trend, the rates of exclusive and predominant breastfeeding across most Ethiopian regions fluctuated in a similar pattern from 2000 to 2019 (Figure 2). A possible explanation might be that mothers from Gambella might receive interventions of different intensities or qualities than mothers from other regions. Exclusive breastfeeding was higher in rural areas than in urban areas and declined ~2005, followed by an increase in 2016 and a decline again which is consistent with a systematic review and meta-analysis findings from Ghana (41). Higher exclusive breastfeeding rates in rural areas of Ethiopia compared to urban areas may be attributed to factors such as traditional postpartum care practices, limited access to commercial formula milk products, and lower socioeconomic status among rural mothers (41, 42). Similarly, higher predominant breastfeeding rates were observed in urban areas than in rural areas, where mothers who reside in urban areas could access formula milk and prefer complementary feeding earlier (43). To understand this, we need to consider various factors influencing breastfeeding practices in these settings.

The disparities in exclusive and predominant breastfeeding rates across different geographical and demographic groups in Ethiopia are consistent with global trends (40). These disparities highlight the complex interplay of factors influencing breastfeeding practices (39). Regional state, residence, and maternal religion were significantly associated with the likelihood of practicing exclusive and predominant breastfeeding (p < 0.01) (Table 2). For example, mothers residing in Amhara (AOR: 5.036), Oromia (AOR: 4.418), and former SNNP (AOR: 3.997) have significantly higher rates of exclusive breastfeeding than mothers residing in Somali, which is consistent with previous studies (44). These findings also reflected the rural-to-urban disparities. Higher rates of exclusive and predominant breastfeeding were observed among rural mothers than among urban mothers. These findings were consistent with previous findings (25, 44). These differences might be attributed to differences in socioeconomic status, stronger cultural norms supporting breastfeeding, and limited access to formula in rural areas (41, 42). Additionally, rural areas might have more entrenched cultural beliefs and practices supporting breastfeeding with extended family living arrangements, and larger families could provide more support for breastfeeding mothers (45). Another factor might be that the lower availability of formula in rural areas might encourage exclusive breastfeeding.

Mothers aged 25–29 years are less likely to exclusively or predominantly breastfeed than younger mothers aged 15–19 years are (p < 0.05). While specific studies focusing on this age group might be limited, general trends in breastfeeding and maternal age in which maternal age is significantly associated with exclusive breastfeeding have been explored in the literature (46). The possible explanations might be a greater likelihood of employment at the age of 25–29 years compared with younger mothers and lower family living arrangements and support from family. Differences in exclusive and predominant breastfeeding practices were observed among different religious groups. For example, Protestant and Orthodox mothers in Ethiopia have significantly higher rates of exclusive and predominant breastfeeding than Muslim mothers do (p < 0.001). Several studies have revealed that regions influence various health behaviors and breastfeeding practices (47–49). Potential reasons for religious differences in exclusive and predominant breastfeeding practices might be associated with religious beliefs and practices and the spatial residence of mothers. However, this highlights the need for additional qualitative studies.

The effect of a mother's education level on the likelihood of exclusive and predominant breastfeeding is not clear. Mothers with complete secondary education have a significantly lower prevalence of exclusive and predominant breastfeeding than mothers with no education, which seems counterintuitive. Educational attainment is among the predictors of breastfeeding (47). Conversely, some studies have reported lower breastfeeding rates among educated women, particularly in urban setting (17, 50). For example, analysis of the PMA2023 panel survey data (2021–2023) showed that less educated women in Ethiopia had higher rates of exclusive breastfeeding (50). The possible explanations might be that educated women are more likely to be employed, which can interfere with exclusive breastfeeding and have greater exposure to infant formula marketing.

In contrast to our hypotheses and those of previous studies, marital status (51, 52), employment (25), place of delivery (16, 44), antenatal care utilization (25, 44, 53) and postnatal care utilization (44, 53), and family size (25) were not significantly associated with the likelihood of exclusive and predominant breastfeeding. There might be possible explanations for these counterintuitive findings. The present study used nationally representative data combined from EDHS 2000–2019, whereas other studies were fragmented into different geographical locations. These differences might be due to the study design (sample size, data collection methods, and study period) and the unique characteristics of the national context.

Exclusive and predominant breastfeeding rates have varied across children aged <6 months in Ethiopia and have fluctuated inconsistently over the past two decades. These inconsistent trends in exclusive and predominant breastfeeding and a complex interplay of various factors suggest that previous policies and strategies have had limited success in achieving sustained improvements. The significant influence of regional, residential, and religious factors on the likelihood of these breastfeeding practices highlights the need for targeted and tailored public health interventions about exclusive and predominant breastfeeding. These findings suggest a need for further investigation and revisiting the current policies and implementation strategies for a more nuanced and targeted approach in future interventions. The policy and intervention strategies need to be revised through regular assessments and evaluation research that considers regional differences and sociocultural settings for equitable and sustained improvements in breastfeeding in Ethiopia. Further study is needed to explore the interplay between maternal age, employment status, and breastfeeding practices in more detail, investigating social support networks and childcare arrangements and the knowledge, attitudes, and beliefs about breastfeeding among different age groups of mothers to develop targeted interventions.