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Increasing educational attainment of adolescent girls might avert both a large number of maternal deaths and a significant number of cases of catastrophic health expenditure in the 2 countries.

Conclusions Adolescent pregnancies can lead to large equity gaps and substantial impoverishment in low-income and middle-income countries.

Niger has the highest total fertility rate globally (7.6) and a high maternal mortality ratio (553 per 100 000 live births) leading to 5400 maternal deaths annually.

India presents the largest population in Southern Asia (1.3 billion); it has the largest number of maternal deaths worldwide (45 000 deaths) and a high maternal mortality ratio (174 per 100 000 live births).2–4We quantified per income quintile and per year: (1) the number of adolescent maternal deaths; (2) the total OOP costs induced by complicated maternal deliveries; and (3) the impoverishment caused by complicated deliveries, using an estimated number of cases of catastrophic health expenditure among adolescent women.

It was based on the maternal mortality ratio (174 and 553 per 100 000 live births among 15–49 years old women in India and Niger, respectively), which was distributed across the five adolescent ages (15, 16, 17, 18, 19), based on the relative risk (compared with 20–24 years old women) of maternal mortality among adolescents (4.6, 1.0, 1.0, 1.0, 1.0; table 1) and the per cent of women aged 15, 16, 17, 18 and 19 pregnant (1%, 3%, 5%, 9%, 12% in India and 3%, 12%, 16%, 19%, 18% in Niger; table 1).

We then assigned these adolescent deaths to five income quintiles using the distribution of adolescent pregnancies per income quintile (19%, 17%, 13%, 8%, 3% in India and 41%, 43%, 37%, 32%, 19% in Niger; table 1).

It was based on the occurrence of complicated deliveries (15%; table 1), the relative risk of maternal mortality among adolescents, and the per cent of women aged 15, 16, 17, 18 and 19 pregnant.

We then assigned these OOP costs to five income quintiles using both the distribution of adolescent pregnancies per income quintile and the distribution of healthcare usage per quintile (19%, 29%, 42%, 58%, 80% in India and 13%, 19%, 22%, 30%, 71% in Niger; table 1).

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Adolescent pregnancies remain common, and pregnant adolescent women face elevated risks of maternal mortality and poverty.

Further detail is given in the online supplementary appendix section 1.1.

Second, we estimated the amount of OOP costs related to complicated deliveries and associated transportation costs per income quintile.

We examined the distribution across socioeconomic groups of maternal deaths and impoverishment among adolescent girls (15–19 years old) in Niger, which has the highest total fertility rate globally, and India, which has the largest number of maternal deaths.

Methods In Niger and India, among adolescent girls, we estimated the distribution per income quintile of: the number of maternal deaths; and the impoverishment, measured by calculating the number of cases of catastrophic health expenditure incurred, caused by complicated pregnancies.

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