An estimated 190,000 people have been killed in South Sudan's civil war and when factors such as population displacement, disruption to health facilities and lack of food are included the death toll is at least 383,000, an independent study said.
Fighting broke out in December 2013 after a political disagreement between President Salva Kiir and the former vice president he had sacked, Riek Machar.
A U.N. official said in 2016 that 50,000 people had been killed and nearly a quarter of the population of 12 million uprooted by the fighting, which has often been along ethnic lines.
"About 383,000 South Sudanese have died as a result of the civil war ... The true number may be considerably higher," said the study by researchers at London School of Hygiene and Tropical Medicine, released on Tuesday.
"While it is plausible that some insecurity would have persisted in South Sudan even without the civil war, we are confident that a large majority of the 190,000 violent deaths were attributable to the war itself," it said.
Researchers used to focus on those killed in fighting in estimates of the violence of a conflict, but increasingly they also look at how war has impacted overall death rates by increasing factors such as hunger and infant mortality.
The study, which covered the period between December 2013 to April this year, showed that most of the deaths occurred in Jonglei, Unity and the Equatorias states. The rate of deaths from the violence peaked in 2016-2017.
Presidential spokesman Ateny Wek Ateny said he would check government data before making a comment.
Kiir signed a peace agreement with Machar and other rebel factions in the Ethiopian capital this month. A previous peace deal signed in 2015 fell apart a year later after clashes broke out between government forces and rebels.
In a sign of how fragile the situation is, government forces and the largest rebel group, allied to Machar, clashed in the north of the country on Monday.