Unequal patterns of tuberculosis in women of reproductive age: Insights from the Global Burden of Disease Study 2021

• Persistent global inequalities, with TB DALYs up to 100-fold higher in sub-Saharan African countries compared to high-income regions; • Age-shifting disease dynamics, where TB incidence peaks in women aged 15–24, while mortality and drug-resistant TB burden are highest among those aged 45–49; • A growing contribution of metabolic risk factors (e.g., high BMI) to TB mortality in both high- and low-resource settings, particularly for drug-resistant TB. : Tuberculosis (TB) remains a major global cause of mortality and is a leading cause of death among women of reproductive age (WRA). Untreated TB in this population endangers both maternal and neonatal health, yet the age-stratified burden and the shifting distribution of drug-resistant tuberculosis remain poorly defined in global health agendas. This study aims to employ data from the 2021 Global Burden of Disease Study to systematically evaluate the global, regional, and age-specific burden of TB among WRA, to delineate temporal trends in drug-resistant TB, and to assess associated risk factors using standardized estimation methods. : Leveraging data from the Global Burden of Disease Study 2021 covering 204 countries and territories, we systematically assessed TB burden in WRA aged 15–49 years from 1990 to 2021. We analyzed age-standardized incidence, prevalence, mortality, and disability-adjusted life years across socio-demographic index (SDI) regions, TB subtypes, and risk factors. Projections to 2030 were generated using autoregressive integrated moving average models. : Between 1990 and 2021, the global prevalence and incidence of TB among WRA declined significantly. However, this decline was uneven across age groups, disease types, and regions. TB incidence peaked in women aged 15–24 years, while mortality and disease burden were highest among those aged 45–49 years. Drug-resistant tuberculosis was most prominent in the 25–29 age group. Geographically, sub-Saharan Africa remained the core of the global TB burden, with BRICS (Brazil, Russia, India, China, South Africa) countries carrying significantly higher burdens than G7 countries. Risk attribution patterns revealed a shift from behavioral to metabolic drivers, with high body mass index emerging as the leading risk factor in high-SDI regions. Middle-SDI regions showed a combination of metabolic and behavioral risks, while metabolic factors remained dominant in low-SDI settings. Drug-susceptible tuberculosis was primarily linked to smoking and malnutrition, whereas drug-resistant tuberculosis was increasingly associated with metabolic dysfunction. : Despite global declines in TB prevalence and incidence among WRA, stark disparities persist. The age-stratified rise in drug-resistant TB, particularly in resource-constrained regions, underscores the need for targeted, gender-responsive interventions that integrate infectious disease control with metabolic health strategies.