This post originally appeared on AlignMNH’s website on June 16, 2025.
The arrival of a baby is often described as life’s most profound transformation. Yet, for many women and families, this experience is threatened by a silent killer: tuberculosis (TB), the world’s deadliest infectious disease.
Each year, over 200 million women become pregnant globally. It is estimated that more than 200,000 of them develop TB during pregnancy, but this is likely an undercount. In many parts of the world, TB remains hidden, undetected, and under-diagnosed, especially among pregnant and postpartum women.
Take Lesotho, for example. With a population of just over 2 million, many of whom are under 29 years of age, Lesotho faces intersecting health crises. TB and HIV are the top causes of death in a country that also has a shockingly high rate of maternal mortality (478 deaths per 100,000 live births in 2023). Overall, 54.2% of shared causes of deaths are due to communicable, maternal, perinatal and nutritional conditions.
A hidden danger during and after pregnancy
The risk of active TB is up to two times higher among pregnant and postpartum women in high burden countries. That risk increases even further for those with other co-morbidities such as HIV or gestational diabetes. Pregnant women living with HIV who develop TB are twice as likely to die during the year following the birth compared to women who did not develop TB. Their babies are also at increased risk— three times more likely to die during their first year of life and a higher risk of HIV infection themselves.
While the exact reasons for increased TB susceptibility during pregnancy are not fully understood, some potential factors include immune system changes coupled with hormonal variations that occur during pregnancy and postpartum. Pregnancy naturally suppresses parts of the immune response to protect the fetus, but this immune suppression can also increase the risk and severity of certain infections including TB.
TB in pregnant and postpartum women is frequently overlooked. One reason is symptom overlap: fatigue, weight loss, shortness of breath, and cough are common in both TB and pregnancy, making it difficult to distinguish one from the other. In some cases, TB presents without any symptoms at all. In others, health providers simply may not ‘think TB,’ delaying appropriate diagnostic investigations. And women themselves may not consider TB to be a risk—we once met a woman in Lesotho who told us, “Of all the things that could happen to me and my baby during pregnancy, TB did not even cross my mind. That’s not the type of thing we heard of.”
Even when TB is diagnosed, reporting of this data and outcomes are often not recorded systematically by national TB programs. As a result, the true burden of TB in pregnancy is hidden, and care remains fragmented.
WHO Guidance: REACH, Diagnose, Treat, Prevent
The World Health Organization (WHO) recommends that pregnant and postpartum women in high TB burden settings—especially those living with HIV—receive routine TB screening, diagnosis, treatment and preventive care. These guidelines include:
- Systematic screening for TB: All pregnant and postpartum women in high TB burden countries and all pregnant and post-partum women living with HIV should be screened for TB at every visit to a healthcare facility using a four-symptom checklist (cough, night sweats, fever, weight loss) combined with additional tests, including chest X-rays when appropriate. Unexplained failure to gain weight during pregnancy should also be considered together with weight loss.
- Diagnosis using WHO-recommended tests: Women with presumptive TB should be offered rapid molecular testing as the first step for diagnosis.
- Safe treatment: Standard drug-susceptible TB treatments are safe during pregnancy and should be started immediately upon diagnosis.
- TB Preventive Treatment (TPT): Pregnant women living with HIV without active TB should receive TPT regardless of stage of pregnancy. This improves pregnancy outcomes for both mothers and their infants.
Implementation gaps and challenges
Despite clear guidance, implementation remains inconsistent. Key challenges include:
- Symptom-based screening alone is insufficient: Many pregnant women with TB do not show typical TB symptoms or do not have symptoms at all.
- Difficulties with diagnosis: TB diagnosis is still primarily based on sputum-based tests. Even when TB is suspected, pregnant women often struggle to produce sputum samples for testing.
- Inadequate tracking: Many countries do not systematically track data on TB screening, diagnosis, prevention, and treatment in pregnant or postpartum women. This makes it hard to evaluate program performance or improve care.
- Limited uptake of preventive treatment: Only 64% of countries have policies supporting TPT for pregnant women living with HIV. Even when policies exist, implementation is frequently undermined by insufficient funding, supply chain issues, shortages of healthcare staff, overburdened providers, and lack of adequate training, making it difficult to scale up TB screening and treatment effectively.
The stakes are high, and the clock is ticking
TB is both preventable and curable, yet it remains the world’s leading infectious diseases killer worldwide, causing an estimated 1.25 million deaths globally in 2023, including 161,000 people with HIV. Women of reproductive age account for roughly 20% of the global TB burden. In countries like Lesotho, where maternal deaths and TB deaths are high, failing to address these issues together means lives are needlessly lost.
We are now only five years away from the global target of ending TB by 2030. While the goal is ambitious, it is achievable. Since 2000, an estimated 79 million lives have been saved, and the possibility of ending TB is now within reach. Today, we have better tools than ever, including new diagnostics, preventive therapies, effective treatments, and a promising vaccine candidate on the horizon
But success depends on continued commitment, smarter strategies, and sustained investment. We must integrate TB and maternal health efforts – and within the broader primary health care approach – and reach those most at risk, including pregnant and breastfeeding women and their infants.
Rethinking care
Too often, healthcare systems treat diseases in silos. Pregnant women face an intersection of risks from both maternal health complications and TB, yet these two crises are often treated separately. We need to refocus the health and wellbeing of a person as a whole across every stage of life. This is particularly true for women navigating pregnancy in high TB burden settings.
What does that look like in practice?
- Raise awareness and spur action: TB is a social disease and as such it should no longer be viewed as a health condition in isolation. It must be understood in the context of social determinants of health, primary health care, maternal and child health, HIV, and nutrition.
- Center care on people, not diseases: Person-centered care starts with recognizing the whole individual, not just their disease. We must ensure that care is tailored to individual needs across life stages and epidemiological contexts. For pregnant women living in high TB burden countries, this includes accounting for TB risk and ensuring services are coordinated.
- Engage communities: Women are more likely to seek care when they trust the health system. Community engagement helps co-design health care that works for people, reduce stigma, builds understanding, and improves service uptake.
- Invest in health systems: Stronger TB responses require more and consistent funding investments, leak-proof supply chains solutions, and well-trained healthcare workers. Advocacy efforts at all levels is essential.
- Strengthen data collection and use: Without data, we can’t see the true impact of TB on pregnant women and address gaps in access and quality in care. Countries must continue investing in data systems to track TB services across maternal health care.
- Include pregnant women in research: Pregnant and postpartum women have historically been excluded from TB trials and treatment studies. This must change. Without evidence, they remain locked out of innovations that could save their lives.
We can and must do better
There is no going back. Ending TB isn’t just a goal—it’s a necessity. It requires us all—policymakers, researchers, health workers, advocates, and communities—to break down silos, rethink how care is delivered, and expand our vision of what’s possible.
The path ahead is clear. The tools are available. The evidence is strong.
The only question is: Will we act?