Results
In 2019, the CS rate was 19.56% in total, 14.20% in the public, and 34.47% in the private sector depicting excess CS. The average annual changes from 2011 to 2019 were 8%, 5.83%, and 5.86% for total, public, and private sector rates, respectively (Figure 1a) . While the rates of change for private and public sector CS rates were similar, private CS rate has been high since 2011. In 2019, 32 states crossed the excess threshold for total CS rates while 4 states - Uttar Pradesh, Bihar, Jharkhand, and Meghalaya had inadequate CS rates(Figure 1b) . Excess CS was present in the private sector in 30 states. The public sector in six states had inadequate CS rates. Of the 737 districts, 331 (44.9%) districts had excess CS surgeries while 277 (37.6%) noted inadequacy (Figure 1c) . Zero CS were noted in 24 districts mostly belonging to northeastern states. Most districts with excess sections were clustered in the southern states of Telangana, Tamil Nadu, and Kerala. District-level comparison depicted significantly greater CS rates in the private (n=613, mean=42.43, standard deviation=25.89) compared to the public sector (n=727, mean=16.56, SD=15.65) (Figure 1d) . The private sector in 482 districts had excess CS rates compared to the public sector in 261 districts. The public sector in 337 districts fell below the 10% threshold compared to the private sector in 83 districts.