Malnutrition remains one of the most common causes of morbidity and mortality among children throughout the world. It has been responsible, directly or indirectly, for 60% of the 10.9 million deaths annually among children under five and two-thirds of these deaths, which are often associated with inappropriate feeding practices [1, 2]. Children are most vulnerable to malnutrition in developing countries because of low dietary intakes, lack of appropriate care, and inequitable distribution of food within the household [3, 4]. Over one third of under-five mortality is caused by malnutrition related to inappropriate complementary feeding. Initiate safe and nutritionally adequate complementary foods at 6 month is crucial to achieve optimal growth, development and health [4, 5].

Complementary feeding refers to gradual dietary transition characterized by introduction of solid and semisolid foods to an infant’s diet when breast milk alone becomes insufficient in meeting the nutritional needs of infant. The recommended age range for complementary feeding is generally taken to be 6 to 24 months even though breastfeeding may continue beyond 2 years [1]. Complementary foods are intended to ‟supplement” ongoing breastfeeding and thus facilitate the transition from milk feeding to family foods [6].

The world health organization (WHO) has developed eight core and seven optional indicators to monitor and guide infant and young child feeding practices [7]. Ethiopia is one of the sub Saharan African countries with high level of malnutrition and has launched the national strategy for infant and young child feeding in 2004 to improve the nutritional status of children [8]. WHO recommends a combinations of indicators to measure the level of appropriate complementary feeding, however, most studies conducted so far on complementary practices has used single indicator with narrow age range and thus not adequately quantify the level and determinants of appropriate complementary feeding practices [9]. Among studies conducted using composite indicators, Ethiopia Demographic Health Survey (EDHS) 2011 and study conducted in Abi Adi, Northern Ethiopia showed the level of appropriate complementary feeding to be too low, 4.3% and 10.7% respectively [5, 10]. Furthermore, the information regarding the complementary feeding in the study area is lacking thus this study aimed to assess the prevalence of appropriate complementary feeding practices and associated factors among children aged 6–23 month residing in rural Damot sore district, Southern Ethiopia.

The overall prevalence of appropriate complementary feeding was 11.4%, (95% CI: 8.8, 14.3). This was comparable to the result from Abiy Adi town, North Ethiopia where appropriate complementary feeding was 10.5% [10]. This might be due to similarities in study setup and indicators used to measure appropriate complementary feeding. The result is higher than the Ethiopia national level and South Ethiopia reported from EDHS 2011 in which prevalence of ACFP was 4.0% and 3.% [5]. However, the result was much lower than the findings from Kohat district Pakistan 18.2% Sirlinka, Zambia and Bangladesh where the prevalence of ACFP was above 20% [8, 11–13]. The disparity might be due to the fact that previous studies were used three indicators to calculate ACFP, whereas this study used four indicators [14, 15].

About 74.2% of mothers had started complementary foods at 6 months of child’s age, as recommended. It was higher than the findings from Deheli India 17.5% [16], United Arab Emirates 17% [17], Mekele 62.8% [18], Ethiopia with national levels 51% [5], Harare 54% [4] and Kohat district Pakistan 69.7% [13]. The result is nearly similar with finding from that of Abiy Adi 80% [10]. This high prevalence might be due to practice group through time, better maternal health care service utilization and extensive effort of health extension workers, health development army and women’s development group in the study area.

Minimum acceptable diet, a combination of minimum meal frequency and minimum dietary diversity, was 16.3% which is higher than Ethiopia national level 4% and SNNPR 2.3%, and Abiy Adi, North Ethiopia 11.9%. But, it was lower than the finding from Sirlanka 68%, Bangladesh 40%, Nepal 32%, Delhi, India19.7% [10–12, 19, 20]. The lower level of the result might be due to socio-cultural differences among the study area. The result is consistent with the findings from Tanzania (16.3% Vs 15.9%) [21].

MDD was observed only 16.5% of caregivers were fed their young child with food group four and more from seven food groups namely grains roots and tubers, legumes and nuts, dairy products, flesh foods, vitamin A reached foods, eggs and other fruits vegetables. Ergib Mekibib et al. also reported from northern Ethiopia that 17.8% of mothers fed their child from four and more food groups and the result of this study is lower than findings from Kamba Woreda SNNPR was 23.3%, Delhi, India 32.6% [19, 22].

The prevalence of MMF was higher than national level 4.3% and SNNPR 2.5%. Moreover, the level of minimum meal frequency in the study found to be 94.5%. The result was much higher than the national level 47.9% and SNNPR 48.9% [5].

The study revealed that ANC follow up and birth orders are factors significantly associated with appropriate complementary feeding practices. Mothers who followed antenatal care service were 3.2 times more likely to practice appropriate complementary feeding than those who did not follow the ANC service. This result is similar with the findings in Sirlinka, Nepal; Harare [11, 20, 23] ANC contacts were a significant predictor of appropriate complementary feeding practice. This might be due to the result of information and counseling that the mothers received from health care providers during their antenatal care. Birth order were found to be the predictors ACFP and this result is congruent with the findings from Kemba [22]. This might indicate the previous feeding experience that could enhance appropriate feeding practice.

In this study there were no association of index child age and, appropriate complementary feeding. This result were different findings from Ethiopia and Zambia, Tanzania; Indonesia [8, 21, 24]. This might be due to the difference in socio cultural understanding of mothers about young children can be able to digest all foods. In this study there was no association between education of caregiver’s and appropriate complementary feeding practice. This was disagreed with the findings from Indonesia, Ethiopia and Zambia, Kenya, Nepal and Sirlanka where maternal education is the predictors of appropriate complementary feeding [8, 10, 11, 20, 24, 25]. The possible explanations can be the difference in norms and cultures with geographical difference regarding female education.

Based on the findings, only one out of nine mothers fed complementary foods appropriately to their children. Although the study showed the high prevalence of minimum meal frequency and timely introduction of complementary feeding, the prevalence of minimum dietary diversity and minimum acceptable diet was low which contributed to the lower prevalence of appropriate complementary feeding. The study also identified mothers who have ANC four and more times and had birth order three or four were factors significantly associated with appropriate complementary feeding practice. Appropriate complementary feeding practice should not be measured by considering only one or two indicators, but by using combinations of core indicators. Capacity building should be strengthen for all health care providers including health extension workers, health development army and women’s support group to focus on dietary diversity and feeding frequency. Health care workers should encourage the women to attend and compliance ANC giving attention to premi gravidas.