Introduction Achieving Millennium Development Goal 5 is crucial for Bangladesh. Knowledge about pregnancy danger signs is essential in avoiding maternal death. Currently Bangladesh is addressing selected pregnancy danger signs across the nation. The objective of this study was to determine the effect of improved pregnancy danger sign knowledge on institutional delivery.

Methods The International Center for Diarrhoeal Disease Research Bangladesh has been maintaining a Health and Demographic Surveillance System (HDSS) since 1966. A maternal, child health and family planning programme was introduced in 1977 in half of the HDSS area. A pictorial pregnancy follow-up card was introduced in 1987 and five selected pregnancy danger signs (bleeding, headache, oedema, mal-presentation, prolonged labour) pictures were included in 2000. The service providers asked each woman about each picture during her 1st & succeeding antenatal care visit.

Results 5538 women who gave birth during 2003 and 2004 were included in the analysis. Knowledge of at least one pregnancy danger sign was increased from 6.7% (192/2841) to 38.5% (1103/2865) in 2003 and 7.5% (196/2610) to 45.3% (1212/2673) in 2004 at first and succeeding visits respectively. Those women who knew at least one pregnancy danger sign were 1.34 (OR 1.34, 95% CI 1.05 to 1.71) and 1.21 (OR 1.21, 95% CI 1.07 to 1.36) times more likely to have a facility delivery than who didn't (adjusted).

Conclusion Bangladesh should aim to make the pictorial tool available in rural area and ensure to ensure that women understand the danger messages.