Background: The aim of this study is to examine rates of magnesium sulfate utilization by emergency obstetric care trainees to treat preeclampsia–eclampsia in India. Secondarily, structural barriers are identified which limit the use of magnesium sulfate, highlighting limitations of emergency obstetric care training, which is a commonly implemented intervention in resource-poor settings. Methods: Trainees’ curriculum specified magnesium sulfate treatment for eclampsia and severe preeclampsia. Case records were analyzed for preeclampsia–eclampsia diagnosis, magnesium sulfate utilization, delivery route, and maternal and neonatal outcomes from 13,238 reported deliveries between 2006 and 2012 across 75 district hospitals in 12 Indian states. Results: Of 1320 cases of preeclampsia–eclampsia, 322 (24.4%) had eclampsia. Magnesium sulfate was given to 12.9% of preeclamptic and 54.3% of eclamptic women, with lower usage rates in rural communities. Among the 1308 women with preeclampsia–eclampsia, only 24 deaths occurred (1.8%). In contrast, among the 17,179 women without preeclampsia–eclampsia, there were 95 reported deaths (0.6%). Both maternal mortality ratios were found to be much higher than the Millennium Development Goal target of 0.15%. Magnesium sulfate administration was associated with a higher death rate in preeclamptic but not eclamptic women, representing possible confounding by severity. Conclusion: To optimize resources spent on emergency obstetric care training, the consistent availability of magnesium sulfate should be improved in India. Increasing drug availability, implementing clinical guidelines around its administration, and training health-care providers on the identification and treatment of preeclampsia–eclampsia could lead to notable improvements in maternal and infant mortality.