Global estimates of tuberculosis incidence during pregnancy and postpartum: a rapid review and modelling analysis

Background

Despite known maternal, perinatal, and infant health risks of tuberculosis during pregnancy, global estimates of incidence remain scarce. Existing estimates are outdated, and do not include the postpartum period, HIV co-infection, age, or specific changes in risk, limiting our understanding of the true scale of disease in this understudied population.

Methods

In this rapid review and modelling analysis, we estimated the global tuberculosis incidence in pregnant and postpartum women using a population-based modelling approach. We searched MEDLINE and EMBASE, with no date or language limits, and included studies reporting tuberculosis incidence in pregnancy or postpartum with suitable comparison groups; we also used Feb 6, 2025, interim data from the ongoing ORCHID cohort. We combined WHO age and sex-stratified tuberculosis incidence data with country-specific population and fertility data to estimate baseline tuberculosis incidence, and applied systematic review-based risk ratios to account for elevated increased risk during pregnancy and postpartum. Uncertainty in all inputs was propagated using standard error propagation formulae and summarised as mean tuberculosis incidence rates and mean incidence rate ratios (IRRs), each reported with 95% quantile-based uncertainty intervals (UIs).

Findings

We identified 37 studies published between 1996 and 2020, of which three were of sufficient quality to provide data for HIV-negative women. One additional study (ORCHID; Odayar et al, unpublished) provided data for women living with HIV. Compared with non-pregnant women without HIV, tuberculosis IRRs were 1·34 (95% CI 1·17–1·54) during pregnancy and 1·91 (1·53–2·39) during postpartum among HIV-negative women. For women living with HIV, IRRs were 5·73 (95% CI 2·64–10·94) during pregnancy and 3·58 (0·85–9·63) postpartum. We estimated 239 500 pregnant women (95% UI 216 300–262 800) and 97 600 postpartum women (90 100–105 200) developed tuberculosis disease globally in 2023, with HIV contributing to 21·3% (19·8–22·8) and 10·6% (9·9–11·3) of cases, respectively. The WHO African region had the highest incidence (110 600 [95% UI 96 700–124 500] in pregnant women and 40 900 [36 300–45 400] in postpartum women), followed by the South-East Asia region (79 900 [64 100–95 700] in pregnant women and 35 900 [30 800–41 100] in postpartum women).

Interpretation

Pregnant and postpartum women face substantial tuberculosis risk, yet remain under-represented in global estimates. Our findings underscore the need for improved surveillance and targeted interventions to reduce tuberculosis incidence in this group.

Funding

UK Medical Research Council.