Background <p>Effective counselling, consent, and debriefing (CCD) are essential for respectful, quality cesarean section (CS) services but limited evidence exists. We explored providers and clients’ perceptions and practices regarding CCD for CS in India.</p> Methods <p>A mixed-methods study was conducted in seven purposively selected secondary level hospitals (five public, two private) across two states. Key-informant interviews and in-depth interviews (<i>N</i> = 108) with providers, women and their relatives, and community workers were conducted in all seven hospitals. Focused ethnography and record reviews of case sheets (<i>n</i> = 797) were conducted in only four public hospitals. Focus group discussions (<i>n</i> = 19) were conducted in the community. Thematic analyses of qualitative data and descriptive analyses of record reviews were conducted.</p> Results <p>Providers understood the purpose of universally practiced counselling. However, this was only unidirectional information sharing of indication and necessity of CS. Clients were not actively engaged: either providers were inaccessible, or clients were hesitant to ask questions. Both providers and clients considered consent primarily useful for protection against any litigation against the provider. Consent process was limited to obtaining signatures. The primary consenters were husbands or in-laws/parents, however, husbands/male relatives were not engaged until the stage of obtaining signatures. Women’s signatures were mandatory in Karnataka. Public hospitals had standard short one-page consent forms in English, while private hospitals had detailed forms in local languages. The term debriefing was not known or used, and concerned practice was rarely observed.</p> <p>Variation in quality of CCD practices was observed with providers’ attitudes and communication skills, workloads, facility norms, and availability of resources. For clients, cultural context, lower socio-economic status, lack of obstetric awareness, limited understanding of their shared decision-making rights, reluctance to question providers, and women’s poor agency negatively affected the CCD process. Mutual lack of trust, poor communication, and low felt need were other barriers.</p> Conclusions <p>Counselling and consent signing for CS, although widely practiced, are of suboptimal quality. Providers believe they counsel adequately within the resource and workload constraints. Clients have limited autonomy in decision making but have higher expectations for receiving detailed information. Appropriate protocols, resources and capacity building are required for both providers and clients.</p>