Geographic inequalities in exclusive breastfeeding among infants under six months across 18 African countries

Exclusive breastfeeding (EBF) is essential for infant survival, growth, and development. Despite known benefits, national averages often mask adherence to coverages and underlying geographic inequalities. While previous studies have examined national averages, less is known about how EBF rates vary within countries. This study assessed national and subnational disparities in EBF among infants under six months across 18 African countries using comparable 2019 estimates. This retrospective cross-sectional ecological analysis used existing 2019 modelled EBF estimates from the Institute for Health Metrics and Evaluation (IHME), accessed through the World Health Organization (WHO) Health Equity Assessment Toolkit (HEAT, 2024 update). EBF estimates follow the WHO 24-hour recall definition for infants aged 0–6 months. Geographic inequalities were quantified using difference (D), ratio (R), population attributable risk (PAR), and population attributable fraction (PAF) using WHO HEAT’s built-in analytical tools. Spatial patterns were visualised using QGIS. National prevalence of EBF ranged from 14.4% in Comoros to 65.9% in São Tomé and Príncipe. Only Ghana, Lesotho, São Tomé and Príncipe, and Zambia exceeded the 2019 global average of 43.5%. Subnational disparities were evident across nearly all countries, with the widest inequalities observed in Nigeria (D = 38.24, R = 9.13, PAF = 116.55%), Tanzania (D = 46.8, R = 2.69, PAF = 42.5%), and Cameroon (D = 24.21, R = 2.67, PAF = 45.48%). In contrast, São Tomé and Príncipe, Lesotho, Comoros, and Eswatini showed minimal regional variation (D ≤ 6, PAF < 7%). On average, one-third of national disparities could be reduced if all regions matched the prevalence of the best-performing areas. EBF coverage across the 18 African countries remains highly uneven despite sustained global and national promotion efforts. While a small number of countries have achieved relatively high and uniform coverage, most continue to experience pronounced subnational gaps. Addressing these inequalities will require region-specific breastfeeding interventions, strengthened maternal support systems, and the systematic integration of equity considerations into national nutrition programmes. Enhanced subnational monitoring and multi-sectoral action will be essential for accelerating equitable progress toward the WHO global nutrition target of 70% EBF by 2030.