Trends in nulliparous singleton alive births by cesarean section in India: Empirical patterns across public and private hospitals for 720 districts, 2016-2021.

Unnecessary cesarean surgeries pose significant short and long-term risks, affecting fertility, future pregnancies, and child health outcomes. Timely monitoring and precise targeting are crucial to mitigate additional health and economic burdens. This study examines trends and patterns in cesarean deliveries among nulliparous singleton births across all 36 states and 720 districts in India, comparing public and private hospitals between 2016 and 2021. Using a repeated cross-sectional analysis of two waves of India's National Family Health Survey, we assess the prevalence of cesarean births and explore how the relative contribution of different geographical levels (villages/blocks, districts, states) to the total variation has evolved over time. At the national level, cesarean rates in public facilities declined by 1.2 percentage points, while private facilities saw an increase of 2.1 percentage points. Regional disparities were evident, with Telangana and Jammu & Kashmir consistently reporting the highest cesarean rates in both sectors. Variation across states was more pronounced than at other geographical levels. In private hospitals, the state-level variance partitioning coefficient increased from 69.2% in 2016 to 78.2% in 2021, whereas in public hospitals, it rose from 44.7% to 48.6% over the same period. Notably, states such as Tamil Nadu, Telangana, and Kerala had nearly all districts falling into the high-prevalence category. It is important to consider burden and variation among smaller geographical units (like districts) to monitor the burden. Increased inter-state inequalities with high prevalence among private facilities in southern states imply the absence of uniform protocols for cesarean births. This calls for urgent policy action to regulate the healthcare sector about the issue, and more awareness is required to avoid the additional health and economic burden.