Objective: The incidence of maternal mortality due to hypertensive disorders of pregnancy in the Netherlands is greater than in other Western countries. We aimed to confirm and explain this difference by assessing incidence, risk factors, and substandard care of eclampsia in the Netherlands. Methods: In a nationwide population-based cohort study, all cases of eclampsia were prospectively collected during a 2-year period (2004-2006). All pregnant women in the Netherlands in the same period acted as reference cohort (n=371,021). Substandard care was assessed in all cases. A selection of cases was extensively audited by an expert panel. Main outcome measures were incidence, case fatality rate, possible risk factors, and substandard care. Results: All 98 Dutch maternity units participated (100%). There were 222 cases of eclampsia, for an incidence of 6.2 per 10,000 deliveries. Three maternal deaths occurred; the case fatality rate was 1 in 74. Risk factors in univariable analysis included multiple pregnancy, primiparity, young age, ethnicity, and overweight. Prophylactic magnesium sulfate was given in 10.4% of women, and antihypertensive medication was given in 39.6% of women with a blood pressure on admission at or above 170/110 mm Hg. Additionally, substandard care was judged to be present by an expert panel in 15 of 18 audited cases (83%). Conclusion: The incidence of eclampsia in the Netherlands is markedly increased as compared with other Western European countries. Substandard care was identified in many cases, indicating the need for critical evaluation of the management of hypertensive disease in the Netherlands.