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Authors’ reply We strongly agree with Ann Blanc, who clearly highlights the dangers of so-called accepted wisdom based on limited or flawed evidence, and the need to question and probe the provenance of data used to direct resources and plan policies. This is indeed an important lesson for the maternal health community as we move forward with setting priorities for national and global maternal health agendas. We would also like to emphasise that we do not see our findings as negating the need to focus on reducing adolescent births in some contexts. Increased risk of mortality is only one of the potential negative outcomes that can result from early motherhood, and a holistic approach that assesses evidence of potential adverse effects on education, opportunities, and general wellbeing, as well as health (for mother and baby) should be used to guide policy in this area. We were also unable in our study to estimate whether younger adolescents (eg, aged 12–15 years) experienced higher mortality than their older adolescent counterparts, and this is an area we will be researching in future to further develop our understanding of risks to young mothers. We declare that we have no competing interests.

Summary Background Adolescents are often noted to have an increased risk of death during pregnancy or childbirth compared with older women, but the existing evidence is inconsistent and in many cases contradictory. We aimed to quantify the risk of maternal death in adolescents by estimating maternal mortality ratios for women aged 15–19 years by country, region, and worldwide, and to compare these ratios with those for women in other 5-year age groups. Methods We used data from 144 countries and territories (65 with vital registration data and 79 with nationally representative survey data) to calculate the proportion of maternal deaths among deaths of females of reproductive age (PMDF) for each 5-year age group from 15–19 to 45–49 years. We adjusted these estimates to take into account under-reporting of maternal deaths, and deaths during pregnancy from non-maternal causes. We then applied the adjusted PMDFs to the most reliable age-specific estimates of deaths and livebirths to derive age-specific maternal mortality ratios. Findings The aggregated data show a J-shaped curve for the age distribution of maternal mortality, with a slightly increased risk of mortality in adolescents compared with women aged 20–24 years (maternal mortality ratio 260 [uncertainty 100–410] vs 190 [120–260] maternal deaths per 100 000 livebirths for all 144 countries combined), and the highest risk in women older than 30 years. Analysis for individual countries showed substantial heterogeneity; some showed a clear J-shaped curve, whereas in others adolescents had a slightly lower maternal mortality ratio than women in their early 20s. No obvious groupings were apparent in terms of economic development, demographic characteristics, or geographical region for countries with these different age patterns. Interpretation Our findings suggest that the excess mortality risk to adolescent mothers might be less than previously believed, and in most countries the adolescent maternal mortality ratio is low compared with women older than 30 years. However, these findings should not divert focus away from efforts to reduce adolescent pregnancy, which are central to the promotion of women's educational, social, and economic development. Funding WHO, UN Population Fund.