OBJECTIVE: To estimate the incidence of eclampsia, characterise maternal and perinatal profiles, and document outcomes across seven countries within the International Obstetric Survey System and identify inter-country differences that may improve maternal and perinatal care. DESIGN: Multi-country analysis of population-based cohort data. SETTING: Six high-income countries (Belgium, France, Italy, the Netherlands, Norway, Slovakia) and one upper-middle-income country (Suriname). POPULATION: All women admitted with eclampsia in participating countries between 2012 and 2019. METHODS: Individual participant data meta-analysis. MAIN OUTCOME MEASURES: Incidence of eclampsia, maternal demographics, pregnancy characteristics, clinical management, mode of delivery and maternal and perinatal outcomes. RESULTS: 615 cases of eclampsia were notified resulting in a pooled incidence of eclampsia of 2.2 per 10,000 deliveries in high-income countries and 36.6 per 10,000 deliveries in Suriname. About 42% of women were diagnosed with preeclampsia before seizure onset and one-third experienced their first seizure postpartum. Hypertension was the most reported clinical sign (91.1%). Most women were treated with magnesium sulphate (91.1%) and antihypertensive medications (89.8%). Caesarean section was performed in 72.7% of cases. About 53% of births was preterm with most of them linked to antepartum cases. Maternal and neonatal deaths were rare but more frequent in Suriname. CONCLUSIONS: The declining incidence of eclampsia in Europe may be attributed to enhanced management, supported by ongoing audits and confidential enquiries; however, potential ascertainment bias limits causal interpretation. Global efforts remain crucial to promote awareness, timely prevention and implement standardised management guidelines for eclampsia across all settings.