Objective: This study aimed to investigate maternal and neonatal outcomes of pregnancies complicated by pre-eclampsia (PE) in Indonesia and analyze regional variations in risk factors and clinical outcomes across the country. Methods: A multicenter retrospective cohort study was conducted in 30 hospitals located across five major islands in Indonesia (Java, Sumatra, Kalimantan, Sulawesi, and Bali-West Nusa Tenggara) between January 2022 and December 2023. Data were collected from medical records, including demographic characteristics, risk factors, and clinical outcomes. Results: A total of 6763 pregnancies complicated by PE were analyzed. The maternal mortality rate was 1.6%, while the stillbirth and neonatal mortality rates were 5.7% and 6.1%, respectively. Severe PE was observed in 69% of cases, and preterm PE occurred in 35.5%. High rates of cesarean deliveries (72.4%) were recorded. Key risk factors included obesity (50.4%), primiparity (27.5%), and chronic hypertension (20.5%). Regional disparities were noted, with Sulawesi reporting the highest maternal (4.7%) and neonatal (7.7%) mortality rates. Complications such as hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome (8.9%), eclampsia (7.4%), and others requiring intensive care unit (ICU) admission (12.6%) were significant contributors to adverse pregnancy outcomes. Conclusion: PE continues to pose substantial risks for maternal and perinatal health in Indonesia, despite reductions in mortality rates. Variations in regional outcomes underscore disparities in healthcare accessibility and infrastructure. These findings emphasize the need for strengthened national strategies, including early screening, improved clinical management, and targeted interventions to reduce morbidity and mortality associated with PE. © 2025 The Author(s). International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.