Tuberculosis Screening During Pregnancy: A Systematic Review of Policies, Practices, and Perceptions Across Global Settings

Abstract

Tuberculosis (TB) remains a leading infectious disease threatening maternal and neonatal health, especially in low- and middle-income countries. Although WHO promotes integrating screening into antenatal care, implementation across countries remains inconsistent and often insufficient. In Indonesia, TB screening is a critical component of antenatal care due to the high prevalence. This systematic literature review aimed to synthesize global evidence on TB screening among pregnant women, with a focus on policies, practices, and implementation challenges, particularly within the Indonesian context. Following PRISMA 2020 and Joanna Briggs Institute guidelines, a comprehensive search was conducted across PubMed and Scopus. Studies published between 2010 and 2025 were included. Ten eligible studies with diverse methodologies were identified, ranging from policy reviews to behavioral and epidemiological analyses. Results showed that only 64% of countries included TB screening for pregnant or breastfeeding women in their policies. Most low-middle income countries also still rely on symptom-based screening rather than advanced diagnostics such as interferon-gamma release assays (IGRA) or Quantiferon testing. Behavioral factors, stigma, and limited health infrastructure further reduce screening uptake. In Indonesia, TB screening during pregnancy remains sporadic and poorly integrated into maternal health services. This review highlights the urgent need for context-specific screening models, stronger policy alignment, and better integration of TB and maternal health programs to improve early detection and reduce the burden of maternal TB.

Introduction

Tuberculosis (TB) remains one of the leading infectious causes of death worldwide despite decades of global control efforts. According to the World Health Organization (WHO) Global Tuberculosis Report 2024, an estimated 10.8 million people contracted TB in 2023, which translates to a global incidence of approximately 134 cases per 100,000 population, and the disease was responsible for 1.25 million deaths that year.¹ Global efforts are still far from meeting the End TB Strategy targets, which sets a 90% reduction in TB incidence and 95% reduction in deaths by 2035 despite significant progress in diagnosis and treatment.^2,3 Low- and middle-income countries (LMICs), where socioeconomic disadvantages, health disparities, and high prevalence of HIV continue to fuel transmission, are particularly impacted by TB. Despite having significant implications on the health of both the mother and the newborn, TB is a frequently disregarded cause of morbidity and mortality among women of reproductive age.

The physiological and immunological changes that occur during pregnancy, which include a temporary suppression of cell-mediated immunity, cause an increase to susceptibility for TB infection and disease progression.⁴ TB poses significant health risks to both the mother and fetus when contracted and developed during pregnancy. Pregnant women with active TB are at a higher risk of maternal mortality and experience a higher incidence of obstetric complications, including anemia, pre-eclampsia, preterm labor, and postpartum haemorrhage.⁴ In severe cases, TB can result in congenital or neonatal TB, premature delivery, low birth weight, and intrauterine growth restriction.⁵ These risks are further worsened by the coexistence of HIV infection, as mothers who contracted both TB and HIV experience faster disease progression and lower treatment outcomes.⁶ Currently, estimates of the incidence of TB in pregnant women are limited, with global estimates in 2019 by WHO suggesting about 151.000 women develop TB during pregnancy annually.⁷ This number could be an underestimate, as TB remains frequently undetected during pregnancy due to the fact that its initial symptoms, including fatigue, weight loss, and a moderate cough, are frequently misinterpreted as typical gestational changes. Consequently, the prevalent occurrence of delayed diagnosis continues to threaten the wellbeing of newborns and damage maternal health.

As such, the integration of TB screening, prevention, and care within existing health systems, particularly maternal and child health services, is emphasized in the WHO End TB Strategy (2015–2023).² The WHO guidelines recommend that all pregnant women living with HIV and those residing in TB-endemic regions be routinely screened for TB during antenatal care (ANC) visits. This screening should be conducted using symptom-based algorithms and, when necessary, additional diagnostic testing, such as chest radiography with abdominal shielding or bacteriological confirmation.⁸ The strategy also advocates for the provision of TB preventive treatment (TPT) to eligible women in order to reduce the risk of progression from latent infection to active disease. However, the implementation of these global policy commitments is still unequal. The absence of clear operational guidance, adequate funding, and inter-program coordination between TB and maternal health services in numerous countries has resulted in missed opportunities for early detection and treatment.⁹

In Indonesia, TB remains a significant public health challenge and continues to be one of the most significant burdens. WHO (2024) reported that Indonesia is the third-largest contributor to global TB incidence contributing approximately 10% of the case globally, or about 969,000 new cases annually. They also estimated that the national incidence of TB is 354 cases per 100,000 people, and TB is responsible for approximately 187,000 deaths anually.¹ The Ministry of Health of the Republic of Indonesia has implemented the National TB Control Strategy 2020–2024, which is in accordance with the WHO End TB Strategy. This strategy prioritizes early case detection, universal access to treatment, and integration with high-risk health services, including maternal and child health.¹⁰ Despite this policy commitment, TB screening for pregnant women in Indonesia is primarily symptom-based and opportunistic, rather than a routine component of ANC.^11–13 Consequently, latent TB infection (LTBI) and asymptomatic active TB cases commonly remain undetected.

Effective implementation is further delayed by operational challenges. In rural areas, Indonesia is confronted with persistent shortages of trained healthcare workers, limited laboratory capacity, and unequal diagnostic infrastructure.¹⁴ Additionally, the stigma associated with TB continues to discourage women from undergoing testing or treatment, and the fragmented delivery of services is a result of the insufficient coordination between TB and reproductive health programs.¹⁴ The lack of research on TB during pregnancy in Indonesia is evident, with the majority of studies concentrating on general epidemiological trends or program evaluation, rather than on antenatal screening specifically. Although the prevalence of TB among pregnant women is comparable to that of the general population, there is a lack of dependable data from ANC-based screening.¹⁵ This lack of empirical evidence highlights a critical gap, which is despite the fact that TB in pregnancy is a significant public health issue, the evidence regarding screening practices, diagnostic methodologies, and program feasibility in LMICs, particularly Indonesia, is still inadequate.

Given these challenges, it is crucial to streamline the fragmented body of evidence regarding TB screening during pregnancy. Strategies that enhance early detection and maternal outcomes can be informed by an understanding of the various approaches taken by health systems to screening, ranging from global policy frameworks to local implementation. Through a systematic review of existing literature, the most effective, feasible, and context-appropriate screening models will be identified, and the gaps that persist in research and practice will be clarified. Therefore, this systemic literature review aims to synthesize current evidence on TB screening among pregnant women, with a focus on global policies, practices, and obstacles to implementation, with contextual relevance for Indonesia.

Materials and Methods

Study Design

This review implemented a Systematic Literature Review (SLR) approach to compile and critically analyze existing evidence on TB screening among pregnant women. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA)¹⁶ statement to ensure transparency and methodological rigor. The protocol was developed in accordance with the recommendations of the Joanna Briggs Institute (JBI) for synthesis of evidence in public health research.¹⁷ The objective of this review was to review was to compile global evidence regarding TB screening policies, diagnostic practices, and implementation challenges in pregnancy, with a specific focus on LMICs such as Indonesia. The review sought to identify gaps, emphasize best practices, and inform future strategies for integrating TB screening into maternal health services by combining data from multiple regions and research designs. The detailed protocol of the current study has been registered on the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD420261425282.

Search Strategy

A comprehensive and systematic search was conducted across multiple academic databases and institutional sources between January and April 2025. The databases searched included PubMed/MEDLINE and Scopus. The search strategy employed Boolean operators (“AND”, “OR”) to refine the results, combining Medical Subject Headings (MeSH) and free-text keywords. The primary search term was as follows:

(“tuberculosis” OR “TB”) AND (“pregnant women” OR “pregnancy” OR “antenatal” OR “maternal”) AND (“screening” OR “testing” OR “detection” OR “diagnosis”) AND (“policy” OR “implementation” OR “program” OR “practice”)

In accordance with the time frame of the WHO End TB Strategy (2015–2035) and contemporary public health interventions, the search was restricted to studies published between 2015 and 2025.

Eligibility Criteria

Eligibility was determined using the PICO (Population, Interest, and Context) framework to ensure a structured and transparent selection process. The inclusion and exclusion criteria are summarized below (Table 1).

Table 1.

Inclusion and Exclusion Criteria for Article Selection¹⁸

Criteria	Inclusion	Exclusion
Population	Pregnant women, including those in antenatal or immediate postpartum care	Non-pregnant adults, men, or general TB populations
Interest	TB screening practices, policies, and implementation (including TST, IGRA, QFT, and symptom-based screening)	Studies focused only on TB treatment outcomes or unrelated comorbidities
Context	Global and regional health system settings, with emphasis on LMICs and Indonesia	Studies outside public health or healthcare delivery contexts
Study Design	Qualitative, quantitative, or mixed-methods research; program evaluations; systematic reviews; and policy analyses	Editorials, letters, conference abstracts, and commentaries
Language	English or Bahasa Indonesia	Other languages without translation
Publication Period	2010–2025	Publications before 2010

Study Selection Process

The Mendeley Reference Manager was used to organize and eliminate duplicates, and all identified records were exported. The screening process was divided into two phases. First, two researchers independently reviewed the titles and abstracts to determine their relevance. All potentially eligible studies underwent full-text screening. In the event that consensus was not achieved, a third reviewer was consulted, and differences in inclusion decisions were resolved through discussion. The number of studies identified, filtered, excluded, and ultimately included in the review was documented using a PRISMA 2020 flow diagram in (Figure 1). This guaranteed a transparent audit trail of the selection process.

Figure 1.

PRISMA Statement: TBC Screening during Pregnancy.

Data Extraction

Data were extracted using a standardized template adapted from the JBI Data Extraction Tool for various evidence synthesis. The subsequent data was documented for each article review: Author(s) and year of publication, Study location/Country, Research objectives and methods, Type of TB screening or diagnostic approach employed, Data analysis methods, Grand theories, Key findings, Study limitations, and Recommendations for future studies. In order to ensure reliability, data extraction was conducted independently by two reviewers. Consensus was reached to resolve any inconsistencies.

Quality Appraisal

This review uses The JBI Critical Appraisal for assessing the selected articles’ feasibility. The synthesis of the data outcome is shown in Table 2. There are five assessment items in total for cross-sectional studies reviewed in Table 3, which were the methods used in the majority of articles obtained from the literature search. There are also four assessment items for cohort studies in (Table 4) and one assessment for reported policies in (Table 5). The article is considered feasible if it meets >70% of the assessment criteria.

Table 2.

Assessment of the Quality of the Literature Reviewed

Author, Year	JBI Critical Appraisal Checklist17	Literature Quality Assessment
Rahari et al 202519	100% (8/8)	Feasible
Vijayageetha et al 201920	75% (6/8)	Feasible
Mohammed et al 202021	75% (6/8)	Feasible
Adjobimey et al 202222	75% (6/8)	Feasible
Mohammed et al 202123	75% (6/8)	Feasible
Fröberg et al 202024	82% (9/11)	Feasible
Bullarbo et al 201825	82% (9/11)	Feasible
Molina et al 201626	73% (8/11)	Feasible
Jonnalagadda et al 201527	73% (8/11)	Feasible
Id et al 20249	71% (5/7)	Feasible

Table 3.

JBI Critical Appraisal for Cross-Sectional Study^19–23

No.	Critical Appraisal for Analytical Cross-Sectional Studies	Vijayageetha et al 201920	Mohammed et al 202021	Adjobimey et al 202222	Mohammed et al 202123	Rahari et al 202519
1.	Were the criteria for inclusion in the sample clearly defined?	Yes	Yes	Yes	Yes	Yes
2.	Were the study subjects and the setting described in detail?	Yes	Yes	Yes	Yes	Yes
3.	Was the exposure measured in a valid and reliable way?	Yes	Yes	Yes	Yes	Yes
4.	Were objective, standard criteria used for measurement of the condition?	Yes	Yes	Yes	Yes	Yes
5.	Were confounding factors identified?	Unclear	Unclear	Unclear	Unclear	Yes
6.	Were strategies to deal with confounding factors stated?	No	No	No	No	Yes
7.	Were the outcomes measured in a valid and reliable way?	Yes	Yes	Yes	Yes	Yes
8.	Was appropriate statistical analysis used?	Yes	Yes	Yes	Yes	Yes

Table 4.

JBI Critical Appraisal for Cohort Study^24–27

No.	Critical Appraisal for Analytical Cohort Studies	Molina et al 201626	Jonnalagadda et al 201527	Bullarbo et al 201825	Fröberg et al 202024
1.	Were the two groups similar and recruited from the same population?	Yes	Yes	Yes	Yes
2.	Were the exposures measured similarly to assign people to both exposed and unexposed groups?	Yes	Yes	Yes	Yes
3.	Was the exposure measured in a valid and reliable way?	Yes	Yes	Yes	Yes
4.	Were confounding factors identified?	Unclear	Yes	Unclear	Unclear
5.	Were strategies to deal with confounding factors stated?	No	Unclear	No	Unclear
6.	Were the groups/participants free of the outcome at the start of the study (or at the moment of exposure)?	Yes	Yes	Yes	Yes
7.	Were the outcomes measured in a valid and reliable way?	Yes	Yes	Yes	Yes
8.	Was the follow up time reported and sufficient to be long enough for outcomes to occur?	Yes	Yes	Yes	Yes
9.	Was follow up complete, and if not, were the reasons to loss to follow up described and explored?	Yes	Unclear	Yes	Yes
10.	Were strategies to address incomplete follow up utilized?	Unclear	Unclear	Yes	Yes
11.	Was appropriate statistical analysis used?	Yes	Yes	Yes	Yes

Table 5.

JBI Critical Appraisal for Textual Evidence: Policy⁹

No.	Critical Appraisal for Textual Evidence (Policy)	Id et al 20249
1.	Are the developers of the policy/consensus guideline (and any allegiences/affiliations) clearly identified?	Yes
2.	Do the developers of the policy/consensus guideline have standing in the field of expertise?	Yes
3.	Are appropriate stakeholders involved in developing the policy/guideline and do the conclusions drawn represent the views of their intended users?	Unclear
4.	Are biases due to competing interests acknowledged and responded to?	Yes
5.	Are the processes of gathering and summarizing the evidence described?	Yes
6.	Is any incongruence with the extant literature/evidence logically defended? Are the methods used to develop recommendations described?	Yes
7.	Are the developers of the policy/consensus guideline (and any allegiences/affiliations) clearly identified?	N/A

Data Synthesis and Analysis

Given the diversity of study designs and outcomes, findings were synthesized narratively rather than statistically. The analysis of the included articles is done to give an overview through the article extraction table that includes authors and year, country, context, research methods, analysis, grand theory, result, limitation, and future research. From the article extraction table, we found four overarching domains: (1) Policy and Program Alignment with WHO recommendations; (2) Screening Feasibility and Diagnostic Performance; (3) Behavioral and Perception-Based Factors; and (4) Maternal and Neonatal Outcomes. Additionally, analysis was done on country income level and screening modality to investigate variations in programmatic outcomes, yield, and feasibility.

Results and Analysis

The studies published between 2015 and 2025 on TB screening among pregnant women reveal a comprehensive analysis, including early diagnostic comparisons and broader system, as well as behavioral perspectives. Molina et al (2016) in the United Sates and Jonnalagadda et al (2015) in Kenya compared the traditional Tuberculin Skin Test (TST) with Interferon-Gamma Release Assays (IGRA), demonstrating IGRA’s higher sensitivity, improved completion rates, and practical advantages for antenatal care.^26,27 These early findings helped define technical standards for TB screening in pregnancy. The feasibility and cost-effectiveness of universal screening in low-prevalence populations were investigated in subsequent studies conducted in high-income countries, including the United States and Sweden.^24,25 Despite the high levels of participation and treatment adherence, the low number of active TB cases prompted the argument regarding the necessity or cost-effectiveness of universal screening. Meanwhile, LMICs such as India, Indonesia, Ethiopia, and Benin continue to face major implementation barriers.^20–23 Research conducted in these contexts found that symptom-based screening, which remains the primary method in various LMICs, has a significantly low diagnostic yield. However, the integration of TB screening into pre-existing antenatal and HIV programs resulted in enhanced detection and was well-received by women, emphasizing the significance of system-level support.

Year of Publication

A visualization of publications about TB screening in pregnancy from 2015 to 2025 is shown in Figure 2. The data indicates that the research output has been comparatively low over the past ten years, with two to four papers published annually from 2015 to 2023. The number of studies appears to have significantly increased from previous years in 2024–2025, with more than double increase. This change suggests that research on the topic of TB screening is increased globally. The pattern of research features a changing research environment that reflects the increasing awareness of TB screening, particularly in pregnant women, as a public health issue.

Figure 2.

Published Articles on TB Screening in Pregnancy.

Country of Study

(Figure 3) shows the geographical distribution of studies on TB screening during pregnancy, following WHO’s TB burden classification. The data show that low TB burden countries are represented in a fairly proportionate way, but consisting of different research focuses. Sweden and the United States, both low TB burden countries, show that high-income health systems are able to support TB in pregnancy research. On the other hand, high TB burden countries, particularly Ethiopia, India, and Kenya, have similar or higher individual contributions of studies published on TB screening for pregnant women, with each country providing three to four studies. This focus on areas with a lot of TB cases illustrates that TB in pregnancy is becoming increasingly crucial as a public health issue in places with fewer resources. The overall distribution pattern indicates a steady transition towards context-specific evidence creation in poor environments, highlighting the necessity for equitable worldwide research collaboration to address epidemiological and implementation deficiencies.

Figure 3.

Geographical Distribution of Studies on Tuberculosis Screening in Pregnancy by WHO TB Burden Category.

Underpinning Theories

The shift in focus regarding TB screening in pregnancy is reflected in the theoretical frameworks underpinning these studies. Although the majority of studies adhere to the WHO End TB Strategy (2015–2035), recent research conducted by Rahari et al (2025) applied the Health Belief Model (HBM) to investigate the influence of perception and awareness on screening behavior.¹⁹ Furthermore, Id et al (2024) conducted a multi-country policy analysis that revealed discrepancies between global commitments and local implementation.⁹ As illustrated in (Figure 4), the distribution of theories applied across the reviewed literature highlights a growing diversification in conceptual approaches.

Figure 4.

Distribution of Theories Applied in Reviewed Literatures.

In (Table 6) provides a comprehensive summary of the included articles. This review illustrates the progression from technology testing to the comprehension of context, behavior, and policy. Effective TB screening for pregnant women requires not only better diagnostics but also stronger health systems, community engagement, and integrated maternal health strategies.

Table 6.

Summary of Articles^9,19–27

No.	Authors and Year	Country	Context	Research Methods	Analysis	Grand Theory	Result	Limitation	Future Research
1.	Molina et al, 201626	USA	Compared Interferon-Gamma Release Assay (IGRA) and Tuberculin Skin Test (TST) for TB screening in urban, high-risk pregnant women	Observational cohort study (n=141)	Statistical analysis of concordance rates	CDC TB Screening Framework	IGRA had 98% completion rate vs 63% for TST; 96.3% concordance; higher practicality in prenatal care	Small sample, single site, limited diversity	Larger multicenter studies on IGRA performance across pregnancy trimesters and varied risk groups
2.	Vijayageetha et al, 201920	India	Evaluated systematic TB screening among pregnant women in Puducherry antenatal clinic	Mixed methods: cross-sectional (n=4203) + qualitative interviews	Descriptive and thematic analysis	WHO End TB Strategy	Only 0.02% active TB detected; healthcare workers cited low awareness, high workload, weak referral systems	Conducted at tertiary level, not representative; possible underreporting	Assess screening feasibility at primary care; evaluate patient education interventions
3.	Mohammed et al, 202021	Ethiopia	Explored integrating TB screening into general outpatient and reproductive health services	Cross-sectional study	Descriptive and inferential statistics	WHO End TB Strategy	195,713 screened; 309 confirmed PTB (16.7% among symptomatic); increased yield via symptom + CXR screening	Excluded certain subgroups (pregnant, HIV, diabetic); logistical limitations	Evaluate inclusion of pregnant women; long-term impact of integrated screening
4.	Adjobimey et al, 202222	Benin	Investigated prevalence, acceptability, and cost of TB screening among pregnant women	Cross-sectional cost and acceptability study	Descriptive and cost-effectiveness analysis	Public Health Implementation Model	4.1% LTBI prevalence; high acceptability; cost per screened woman ≈ US$10	Limited generalizability; single region	Explore integration of TB screening with ANC and HIV services across West Africa
5.	Jonnalagadda et al, 201527	Kenya	Investigate incidence and cofactors of TB infection (IGRA conversion) among pregnant women with HIV	Cohort study	Statistical descriptive and comparative	Epidemiological TB Control Model	12.4% (17.2% excluding indeterminate) of women converted from negative to positive within 1 year postpartum	Use of cryopreserved rather than fresh PBMCs may have reduced assay sensitivity; lack of TST data; high rate of indeterminate results (28%)	Explore longitudinal studies in pregnant/postpartum women with HIV cohorts in the ART era to assess IGRA conversion rates and refine TB screening/preventive therapy strategies
6.	Mohammed et al, 202123	Ethiopia	Health system perspective on who to involve in TB screening	Cross-sectional diagnostic study	Thematic policy review	Health Systems Strengthening Model	Facility-wide participation improved detection and workflow	Limited by self-report bias and equipment issues	Recommend scale-up models for integrated ANC-TB services
7.	Id et al, 20249	Multi-country (44 PEPFAR-supported nations)	Examined national TB screening and preventive treatment (TPT) guidelines for pregnant and breastfeeding women living with HIV	Document review of national TB/HIV/TPT guidelines	Descriptive comparative analysis	WHO End TB Strategy	64% of countries included TB screening and 80% recommended TPT; many lack breastfeeding-specific guidance	Some guidelines unavailable or outdated; relies on document content not field implementation	Need for harmonized, updated guidelines and research on TPT safety during pregnancy/breastfeeding
8.	Bullarbo et al, 201825	Sweden	Evaluated TB prevalence and screening value among high-risk pregnant/postpartum women	Retrospective cohort (902 women, 2-year follow-up)	Statistical descriptive and comparative	Epidemiological risk-screening model	1/902 active TB; 36% LTBI; no outcome difference between TST+ and TST−	Low TB prevalence limits generalizability; only TST used (no IGRA comparison)	Further studies on cost-effectiveness and alternative methods (IGRA, symptom-based)
9.	Rahari et al, 202519	Indonesia	Explored perceptions of TB and TB screening among pregnant women and healthcare workers	Cross-sectional study (240 women, 126 HCWs, 6 PHCs)	Descriptive & multivariable logistic regression	Health Belief Model (HBM)	Positive perception increased screening intention; most supported TB screening	Limited to one urban area; perception bias possible	Broader multi-regional studies; intervention to improve TB screening acceptance
10.	Fröberg et al, 202024	Sweden	Evaluated systematic TB screening program among pregnant women (Stockholm 2016–2017)	Retrospective observational cohort	Descriptive and inferential statistics	WHO End TB Strategy	QFT screening feasible; 22% QFT+, 9 active TB cases detected, high LTBI treatment completion (94%)	Limited follow-up duration; no cost-effectiveness data	Evaluate long-term maternal/infant outcomes and optimal timing of LTBI treatment

Discussion

The review of five studies that investigated TB screening among pregnant women in a variety of contexts, including global policy evaluations and local hospital-based studies. It provides a comprehensive overview of the challenges encountered, the progress being made, and the methods being used to implement TB screening in maternal health care. The findings indicate that, despite the increasing recognition of the significance of TB screening during pregnancy, there is significant variation in practice between and within countries. Id et al (2024) found that despite the fact that numerous countries have implemented the WHO guidelines for tuberculosis screening and preventive treatment for women with HIV, there are still significant policy gaps, particularly for breastfeeding women.⁹ Studies from high-income countries like Sweden^24,25 concentrated on the practical operation of screening programs, demonstrating that structured systems that implement contemporary tools such as Quantiferon (QFT) are feasible and result in high treatment completion rates. In contrast, studies from Indonesia¹⁹ and India²⁰ highlight a different set of concerns, which is the significance of community perceptions in shaping screening behavior, low case detection rates, and limited resources. This evidence suggests that the challenge is not solely related to the existence of screening tools or policies, but also how those tools are implemented within various cultural contexts and health systems.

Comparative Interpretation: Methods, Settings, and Outcomes

The reviewed studies employed diverse research designs that mirror the priorities and available resources within their respective settings. In high-income countries, researchers tended to use retrospective or observational designs drawing on existing clinical or public health databases to evaluate performance and outcomes. For instance, Bullarbo et al (2018) assessed the effectiveness of the TST among pregnant women in Sweden and found that, although 36% tested positive for LTBI, only one woman developed active TB.¹⁶ This minimal yield raised arguments about the practicality and cost-effectiveness of universal TST screening in low-prevalence settings. Similarly, Fröberg et al (2020) evaluated Sweden’s subsequent QFT-based screening initiative and found it both feasible and efficient, with 22% LTBI detection and a 94% treatment completion rate.¹⁷ These findings illustrate how structured systems and advanced diagnostics in high-income contexts can yield strong outcomes when backed by adequate resources and national coordination.

In contrast, research from LMICs often emphasizes operational feasibility, behavioral factors, and service delivery challenges. Rahari et al (2025) in Indonesia investigated how perceptions and attitudes influence the willingness of pregnant women to undergo TB screening.¹⁹ Using the HBM approach, the study found that women who perceived greater personal risk or recognized the benefits of screening were significantly more likely to participate.²² Similarly, Vijayageetha et al (2019) studied a tertiary hospital in South India, tested a symptom-based screening protocol and reported an extremely low diagnostic yield, demonstrating the inefficiency of symptom-based screening when applied universally.²⁴ The global policy review by Id et al (2024) complemented these studies by analyzing national TB guidelines across different countries.⁹ Although it did not assess patient outcomes directly, it identified wide inconsistencies between international recommendations and national implementation.

Additionally, Jonnalagadda et al (2015) conducted a cohort study in Kenya that evaluated systematic TB screening among HIV-positive pregnant women in primary health care facilities.¹⁵ Their findings reinforced the importance of routine screening in high-burden settings, revealing that despite strong policy support and clinic-based integration, TB detection among HIV-positive pregnant women remained low, with most cases identified only through intensified follow-up. Importantly, the study found that the majority of TB cases occurred among women newly diagnosed with HIV during pregnancy, emphasizing the dual vulnerability of this group.¹⁵ Together, these findings reveal that methodological differences across countries are shaped not only by epidemiological burden but also by diagnostic accessibility, system maturity, and the degree of ANC-TB program integration.

Thematic Synthesis: Policy, Perception, Feasibility, and Outcomes

Policy and Health System Integration

A dominant theme across all reviewed literature is the persistent gap between policy and practice. Id et al (2024) showed that although most LMICs have formally supported TB screening for pregnant women in national strategies, implementation often lags due to inadequate funding, fragmented program structures, and lack of coordination between TB and maternal health services.⁹ However, the study implemented in Sweden demonstrates what can be achieved when policies are clearly operationalized. As Fröberg et al (2020) stated, the integration of TB screening into national ANC protocols, which are supported by digital data tracking and standardized follow-up, resulted in high screening uptake and treatment adherence.¹⁷ Meanwhile, in countries like India and Indonesia, TB screening remains largely opportunistic or symptom-based, delayed by limited infrastructure and inconsistent policy support.^19,20 This disparity underlines the necessity of political commitment, intersectoral coordination, and sustained health system investment to the success of TB screening initiatives.

Screening Methods and Diagnostic Variation

A second recurring theme concerns diagnostic variability. The studies collectively show that settings differ widely in their use of TST, QFT, IGRA, and symptom-based tools. Bullarbo et al (2018) demonstrated that TST provides little diagnostic value in low-incidence settings, whereas Fröberg et al (2020) found QFT testing both accurate and well-accepted.^24,25 However, QFT’s high cost and laboratory demands limit its feasibility in LMICs, where simpler, symptom-based algorithms remain the norm despite their low sensitivity.²⁰ The findings from Jonnalagadda et al (2015) further emphasize that reliance on symptoms alone misses a substantial number of TB cases, arguing for optimized laboratory capacity, enhancing staff training, and ensuring routine testing for positive pregnant women to reduce diagnostic delays.¹⁵ This implies a universal disparity between diagnostic accuracy and affordability, which is one that demands context-specific innovation.

Behavioral Insights and the Health Belief Model

The behavioral dimension adds another critical layer to TB screening discourse. Rahari et al (2025) applied the Health Belief Model to show that women’s decisions to undergo TB screening are influenced by perceived susceptibility, perceived benefits, and trust in healthcare workers.¹⁹ Their findings indicate that even when screening is technically available, uptake remains low if women do not perceive personal risk or if communication from health providers is insufficient. Behavioral and sociocultural barriers, such as stigma, fear, or misinformation, remain significant obstacles in LMICs. Integrating TB education into ANC visits and equipping healthcare workers with culturally sensitive communication skills could substantially increase participation.

Feasibility, Cost-Effectiveness, and Maternal Outcomes

Operational feasibility and cost-effectiveness also emerged as central considerations. In Sweden, Fröberg et al (2020) confirmed that routine TB screening was logistically feasible and well accepted, though Bullarbo et al (2018) questioned its cost-effectiveness given the low incidence.^24,25 In high-burden LMICs, the inverse problem arises, which is that screening is urgently needed but poorly funded.²⁰ Only limited evidence links TB screening directly to maternal or neonatal outcomes, though findings from Sweden suggest that treating LTBI during pregnancy could reduce postpartum TB activation. However, long-term prospective data remain scarce, and most LMICs lack follow-up systems to evaluate downstream health effects. Overall, these insights emphasize that TB screening in pregnancy is feasible but under-implemented; its success requires sustainable financing, diagnostic innovation, behavioral engagement, and true integration within maternal health systems.

Strengths and Limitations of Existing Evidence

The studies reviewed provide a valuable and expanding evidence base for the comprehension of tuberculosis screening during pregnancy. The studies provide a multifaceted perspective on the matter, including policy analysis, epidemiology, and behavioral analysis. However, this review is not without substantial weaknesses, the majority of studies had relatively small sample sizes or limited follow-up periods, which made it challenging to evaluate long-term outcomes. A lack of consistency in screening methodologies also posed a challenge in terms of comparison. The only study to systematically investigate perceptions is Rahari et al (2025), as behavioral and qualitative insights were rare.¹⁹ As discussed by Id et al (2024), the policy-focused assessment article heavily relied on document analysis and do not accurately represent the practical application of these policies.⁹ Overall, the current evidence base is informative but fragmented, emphasizing the necessity of more coordinated, multi-country research that integrates clinical, operational, and behavioral perspectives.

Implications for Practice and Policy

The results of this review have significant implications for health policy and clinical practice. For women from high-prevalence backgrounds or with known exposure, risk-based or targeted approaches remain valuable, although universal TB screening during pregnancy may not always be cost-effective in high-income countries. Meanwhile, it is recommended that LMICs prioritize the integration of TB screening into their existing maternal health programs, rather than implementing parallel vertical programs. The study from Indonesia¹⁹ discusses the importance of community education and healthcare worker engagement to successful implementation. Training programs that enhance provider communication and community trust can assist in overcoming perception barriers. Similarly, policies should encourage the inclusion of TB education within routine antenatal visits to normalize screening. Finally, policymakers should adapt global WHO recommendations to local realities. As suggested by the research in the review, the implementation of standardized yet adaptable guidelines can guarantee that each nation customizes its screening strategy in accordance with its healthcare structure, available resources, and TB burden.

Recommendations for Future Research

The need for future research to expand beyond mere documentation of screening prevalence or program feasibility is vital. It is evident that long-term cohort studies are necessary to comprehend the impact of antenatal tuberculosis screening on the health outcomes of both mothers and fetus. In order to effectively incorporate TB screening into routine ANC services, implementation research should be conducted, while cost-effectiveness studies can be used to guide resource allocation in various settings. Mixed-methods and qualitative research are also necessary to investigate the social and cultural factors that influence screening behavior. Expanding the implementation of behavioral frameworks, such as the Health Belief Model, could offer valuable insights into the ways in which awareness, stigma, and trust affect participation. Finally, it is important to assess the safety, accuracy, and affordability of diagnostic technology innovations, including swift molecular tests, in pregnant populations.

Conclusion

In the past decade, the focus of research on TB screening in pregnancy has shifted from the limited area of which test performs best to the more critical issue of how to make screening work in real ANC systems. Laboratory-based approaches, such as IGRA/QFT have been shown to achieve excellent uptake and completion of latent TB treatment in high-income settings. However, the cost-effectiveness of universal screening of all pregnant women is undetermined due to the extremely low prevalence of active disease. In contrast, a significant number of LMICs continues to rely on symptom-based algorithms that are both cost-effective and easy to implement. However, these algorithms often fail to identify cases, particularly in women who present with mild or atypical symptoms, unless they are incorporated into a comprehensive ANC framework that includes timely referral, targeted follow-up, and clear communication. The second problem concerns policy assessments, as although numerous countries support the principle of TB preventive treatment and screening, operational details for breastfeeding women, referral mechanisms, and routine indicators are unclear, and implementation is inconsistent. It is important to note that behavioral studies agree that TB screening intention and uptake are significantly influenced by perceived susceptibility, perceived benefits, and consistent signals from health workers. Technical capacity is essential, but success is frequently determined by trust and effective counseling. Within the Indonesian context, the evidence highlights the need for closer integration between the National Tuberculosis Program and maternal health services. While symptom-based screening is likely the most practical strategy as a high TB burden country, improvements in health professional training, referral systems, and routine monitoring are essential to enhance case detection among pregnant women. Future research should focus on the validation of risk-based algorithms that identify women with TB-HIV, household exposure, or those who have migrated from high-incidence areas in Indonesia. Multicenter economic evaluations are required to compare universal and targeted strategies while capturing maternal-neonatal outcomes. Practical ANC trials should also be conducted to integrate TB screening, fast referral, and timely initiation of TB preventive therapy with clear process guidelines.

Abbreviations

ANC, antenatal care; HBM, health belief model; IGRA, interferon-gamma release assays; JBI, Joanna Briggs Institute; LMICs, low- and middle-income countries; LTBI, latent tuberculosis infection; PICO, population-interest-context; SLR, systematic literature review; TB, tuberculosis; TPT, tuberculosis preventive treatment; TST, tuberculin skin test; QFT, quantiferon; WHO, World Health Organization.

Disclosure

The authors report no conflicts of interest in this work.