Educational and Counseling Competencies of Midwives in the Prevention of Sexually Transmitted Infections Across a Woman’s Life Course: A Narrative Review

1. Introduction

The global incidence of sexually transmitted infections (STIs) remains a critical public health concern, with World Health Organization data indicating that over one million cases are acquired daily [1]. This epide miological burden involves more than 30 distinct bacterial, viral, and parasitic pathogens transmitted through sexual contact. Strains such as chlamydia, gonorrhea, and syphilis represent the most prevalent bacterial formats, while viral agents including human papillomavirus (HPV), herpes simplex virus (HSV), hepatitis B and C, and HIV can cause long-term health consequences, most notably oncological transformations and reproductive dysfunction [2]. These infections are spread not only through sexual contact, but also through vertical transmission from mother to newborn, through blood components, and through the use of infected needles, including in injection drug use, which significantly increases the risk of infection transmission. When sexually transmitted infections (STIs) are not diagnosed in a timely manner during pregnancy, pregnant women and their newborns are at increased risk of adverse health outcomes. Congenital syphilis can lead to miscarriage and premature birth. Chlamydia and gonorrhea are associated with pelvic inflammatory disease, endometritis, reproductive disorders, and an increased risk of premature birth, as well as a greater likelihood of vertical transmission of HIV. In newborns, chlamydial and gonococcal infection manifests as conjunctivitis and respiratory complications [3]. Human papillomavirus (HPV) causes anogenital warts, precancerous lesions and carcinomas, and persistent infection is a major risk factor for the development of cervical cancer. Evidence suggests that the infection significantly affects women of working age, with cervical cancer being the second most common cancer in young women aged 15 to 44 in Europe [4,5]. Despite available screening, early diagnosis, and treatment methods, sexually transmitted infections (STIs) continue to represent a significant public health problem. Global control is hampered by the high rate of asymptomatic transmission and delayed diagnosis, as well as increasing antimicrobial resistance [6,7]. This combination of factors highlights the need for improved strategies for early detection, systematic follow-up, and effective prevention. Modern obstetrics encompasses a broad and range of care that goes beyond pregnancy and childbirth, but also includes health promotion and prevention, sexual and reproductive health, preconception care, parenthood preparation, breastfeeding support, mental health during the perinatal period, public health, community work, and long-term support for women through various life transitions.

This narrative review aims to analyze and synthesize the educational and counseling competencies of midwives in the prevention of sexually transmitted infections (STIs) based on current international standards and global recommendations. By evaluating these professional frameworks across the distinct physiological transitions of a woman’s lifespan, the paper outlines the clinical and educational structures required to enhance health literacy, lower screening barriers, and support protective sexual health practices. Consequently, this review establishes a specialized competency matrix tailored to the unique reproductive and preventive needs of women at each life stage. This article is developed in connection with an ongoing doctoral research project focused on optimizing the clinical and institutional role of midwives within preventative public health systems.

The educational and counseling responsibilities of midwives are structured around global strategic guidelines and consensus frameworks established by leading health authorities, including the World Health Organization (WHO), the International Confederation of Midwives (ICM), the Centers for Disease Control and Prevention (CDC), and the European Centre for Disease Prevention and Control (ECDC). Taken together, these institutional benchmarks explicitly delineate essential midwifery competencies in healthcare education, clinical screening, counseling, and targeted behavioral support In the prevention of sexually transmitted infections.

2. Institutional Framework and Global Strategic Recommendations

2.1. The WHO Global Health Sector Strategy

The WHO Global Health Sector Strategy on Sexually Transmitted Infections (2016–2021) initiated a foundational paradigm shift in the global management of STIs by establishing a unified prevention model for HIV, viral hepatitis, and sexually transmitted diseases [8]. Grounded firmly in human rights, gender equity, and non-discrimination, this institutional framework prioritizes the expansion of early diagnostic capabilities, universal access to healthcare education, and the systemic integration of sexual health services [8]. Surveillance data published by the European Centre for Disease Prevention and Control (ECDC) reveal an alarming escalation of bacterial STIs across the European continent, highlighted by a 303% surge in gonorrhea cases, a twofold increase in syphilis incidence, and a corresponding rise in congenital syphilis. In response to these epidemiological shifts, European guidelines heavily advocate for universal, sequential screening protocols during gestation, the formal integration of STI testing into established HIV public health programs, and aggressive monitoring of emerging antimicrobial resistance patterns. Furthermore, institutional analyses point to critical gaps in contemporary national policies, noting that restricted access to anonymous testing options, systemic underfunding, and deficient case reporting consistently obscure the true scale of morbidity, thereby severely hindering effective disease management [9,10].

2.2. Evolution of Woman-Centered Clinical Care

The International Federation of Obstetrics and Gynecology (FIGO) emphasizes the link between untreated infections such as chlamydia and gonorrhea and long-term reproductive damage. To interrupt reinfection, FIGO requires simultaneous treatment of both partners. The organization shifts the focus to woman-centered care and recommends screening and treatment of “silent” infections in the preconception period, especially in subfertility and preparation for assisted reproduction [11,12,13]. Within this preventative infrastructure, FIGO identifies midwives as key to prevention: they are responsible for providing health education, promoting HPV vaccination, taking cervical samples (in some countries), and identifying risky behaviors and missed screenings, allowing early referral for diagnosis and treatment [13,14]. In a joint statement on interprofessional collaboration between FIGO and ICM, obstetricians and gynecologists emphasize their support for the professional autonomy of midwives and for making clinical decisions within their scope of competence. The statement adds that midwives have the knowledge and skills to monitor normal, low-risk processes, conduct screening, recognize pathologies, and provide safe, quality, and respectful care in the area of sexual, reproductive, maternal, newborn, and adolescent health (SRMNAH) [15].

2.3. Regulatory Standards and Frameworks for Midwives' Competence

In July 2026, the European Commission updated the minimum training requirements for midwives under Directive 2005/36/EC, introducing mandatory competencies in sexual and reproductive health and the autonomous management of preventive programs. This reform reflects the European vision of high-quality midwifery education as a strategic investment in healthcare, the economy, and gender equality. It highlights that midwives can address over 90% of the needs within the spectrum of sexual, reproductive, maternal, newborn, and adolescent health (SRMNAH), thereby improving health outcomes and reducing the overuse of medical interventions. The modernization of the Directive serves as a critical instrument for sustainable demographic policies, expanded access to reproductive services, and countering digital health misinformation, aligning seamlessly with the EU Gender Equality Strategy [16].

The update of the minimum requirements under Directive 2005/36/EC aims to align with the Essential Competencies for Midwifery Practice and Global Standards for Midwifery Education of the International Confederation of Midwives (ICM). Within the ICM Essential Competencies for Midwifery Practice framework, the midwife is designated as a key specialist in educational and counseling activities related to sexual and reproductive health, including the prevention and recognition of STDs/STIs. The new Category 2 (Sexual and Reproductive Health and Rights) expands the professional scope to include competencies in providing age-appropriate, culturally sensitive, and individualized information, education, and counseling on sexual health, contraception, and the prevention of sexually transmitted infections (STIs). The performance indicators require midwives to engage with diverse groups—including adolescents, women of reproductive age (pregnant and postpartum), and individuals in menopause—ensuring access to evidence-based and culturally competent data. Furthermore, additional competencies in Category 3 (Antenatal Care) and Category 5 (Postnatal Care) emphasize the vital importance of counseling for sexually transmitted diseases (STDs) within the context of pregnancy and the postpartum period, explicitly incorporating screening, clinical referral, and behavioral support for safe sexual practices. Through this framework, the ICM establishes the midwife as a vital professional in prevention and health education for STDs across a woman's entire reproductive life course [17].

In the following table, we structure the core educational and counseling competencies of the midwife in the prevention of STDs, based on international recommendations (WHO, CDC, ICM) and the legally regulated professional activities under Ordinance No. 1 of February 8, 2011, in Bulgaria . This framework provides an opportunity for a comprehensive assessment of the midwife's role in prevention across the distinct periods of a woman's reproductive development (Table 1)

To optimize preventative interventions, the reproductive lifespan of women must be analyzed through a multidisciplinary lens, reconciling demographic, clinical, and epidemiological frameworks.

3. Discussion

3.1. Comparative Demographic, Clinical, and Epidemiological Classifications

The demographic and statistical classification sustained by the UN, WHO, and UNFPA broadly defines the female reproductive period between the ages of 15 and 49, dividing it into five-year intervals to calculate age-specific fertility rates. The early reproductive age group (15–24 years) encompasses adolescent girls aged 15–19 (whose specific adolescent birth rates are explicitly monitored under the UN Sustainable Development Goals); the transitional period of 20–24 years is characterized by high biological fertility alongside rapidly evolving social patterns. The middle phase of optimal reproductive age (25–34 years) includes subgroups aged 25–29 and 30–34, statistically accounting for the highest volume of live births globally. Conversely, the late reproductive phase (35–49 years) includes women aged 35–39, a period marked by a sharp decline in fertility and elevated obstetric risks; those aged 40–44 undergo the perimenopausal transition with significantly reduced fertile capacity; and the 45–49 age bracket encompasses women entering menopause. From a clinical and biological perspective, frameworks established by FIGO, ASRM, and ESHRE evaluate fertile potential based on ovarian reserve and oocyte quality: optimal fertility (20–29 years); early decline of ovarian reserve (30–34 years); late reproductive age or advanced maternal age (35–39 years); and very late reproductive age or very advanced maternal age (≥40 years).In contrast, the epidemiological classification utilized by the WHO, CDC, and ECDC is based on vulnerability to sexually transmitted infections. Here, the focus of the classification shifts from "conceptive capacity" to behavioral risk, anatomical vulnerability, and epidemiological data concerning these infections. The age of 25 serves as the critical baseline separating general public health guidelines from targeted clinical screenings [18]. The CDC mandates annual chlamydia and gonorrhea screening for all sexually active women under 25 (15–24 years), as well as for women aged 25 and older (25–49 years) who present specific risk factors, such as a new sexual partner, multiple partners, a partner with a diagnosed infection, inconsistent condom use, or a personal history of STDs. Furthermore, pregnant women are classified as a high-priority risk group to mitigate vertical transmission. A two-step screening model is recommended: universal testing at the initial first-trimester prenatal visit, followed by repeat screening during the third trimester for all pregnant individuals under 25 and older women exhibiting behavioral risk factors [19].

3.2. Age-Specific Midwifery Competencies Across the Life Course

3.2.1. Puberty and Early Adolescence (Ages 10–14)

The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) define the age group 10–14 years as early adolescence. In the context of sexually transmitted infection (STI) prevention in this group, according to global authorities, primary prophylaxis against HPV and preventive health education have a leading role. The use of age-appropriate clinical history taking and sensitive, non-judgmental communication models allows midwives to effectively assess emerging high-risk sexual and psychosocial behaviors [20,21]. Counseling competencies for this cohort focus on providing development, promoting protective behavioral patterns to prevent STI acquisition, and conducting motivational interviewing to promote self-esteem and personal responsibility. It is crucial that interactive health education and clinical counseling for this adolescent cohort require parental or guardian consent. In Bulgaria, these interventions are strictly regulated by the national Health Act, which legally requires parental consent for minors [22], requiring midwives to navigate both clinical communication and legal frameworks with ease.

3.2.2. Early Sexual Development and Reproductive Maturity (15–24 Years)

The early stages of sexual and reproductive development in the period in which sexual behavior is formed permanently, and risky practices can lead to long-term consequences - infertility, chronic infection and complications in future pregnancies. Therefore, the competencies of the midwife are directly relevant to the development of health culture and behavior of young people. They are directly related to the early detection of risks, breaking the chain of infection transmission and ensuring ethical and culturally sensitive communication. In this context, the professional role of the midwife is based on specific clinical knowledge and consultative training, which support young women in confirming their sexual and reproductive health and in the effective prevention of sexually transmitted infections.

3.2.3. Pregnancy and the Postpartum Period

In the reproductive age during pregnancy, the main counseling competencies are aimed at preparing for a healthy pregnancy, including awareness of systematic screening for HIV, syphilis, chlamydia, gonorrhea and HPV, as well as assessment of the risk of vertical transmission and support for safe behavior. Interprofessional collaboration contributes to coordinated care by ensuring consistent follow-up and counseling on partner testing and management of STI risks [18,23].

The professional role of the midwife during the postnatal period is based on specialized knowledge and skills for counseling and assessment of health care and needs, which contribute to the recovery of the woman and ensure favorable care for the newborn [3]. During this stage, both support for adaptation to parenthood and the promotion of safe sexual behavior and informed choice of contraception are of key importance. The formation of habits for regular preventive gynecological examinations is important for the early detection of risks and for the maintenance of long-term reproductive health [3,18,23].

3.2.4. Perimenopause and Menopause (Ages 40–49)

During the period of perimenopause and menopause, the main professional competencies are aimed at informing about the changes in sexuality and supporting intimate health. A significant part of this consultative process is the referral to appropriate HPV screening and other medical examinations and tests, which are key to maintaining good gynecological health.

3.3. National Regulatory Integration and Epistemological Stratification

Regulation No. 1 of February 8, 2011, clearly regulates the professional activities of the midwife, which significantly support her preventive function. The provisions of Article 5 outline the key competencies in the field of sexual and reproductive health, which are a collection of clinical knowledge and consultative skills, shaping the profile of the midwife in the prevention of STIs.

Care for women of reproductive (fertile) age includes professional support for sexual health and prevention of sexually transmitted infections.

In summary, a clear epistemological distinction needs to be established between women of childbearing age and pregnant women in order to fully validate the structure of preventive obstetric models. By definition, women of reproductive age (15–49 years) are all women of biologically active reproductive age, who are most likely to be sexually active and have reproductive potential. This group is considered a population at increased risk of sexually transmitted infections (STIs) due to the frequency of sexual intercourse, socio-behavioral factors, and the biological predisposition of the female reproductive system to infectious diseases of the genitals, including sexually transmitted infections. In epidemiology, women aged 15–49 years serve as the main denominator in calculating the incidence, prevalence, and prevalence of STIs, allowing for comparability of data across countries and health systems. The group is key for planning prevention programs, screening, health education, and activities to reduce the risk of sexually transmitted infections (STIs) [23,24]. Pregnant women represent a distinct, high-priority clinical subgroup within this population. During pregnancy, the clinical focus shifts fundamentally from preserving long-term reproductive capacity to mitigating immediate obstetric risks—such as miscarriage, preterm labor, or chorioamnionitis—and eliminating vertical transmission of pathogens to the fetus or newborn [3]. While the general fertile population (15–49 years), requires primary prevention based on health literacy—about non-risk behaviors, contraception, and preventive gynecological examinations. The pregnant subcohort requires rigorous secondary prevention through standardized, time-sensitive screening and maternal-fetal monitoring. Recognition of these different physiological, epidemiological and risk management profiles provides the necessary scientific rationale for the matrix developed in this study (Table 1), which segments the midwife's educational and counselling competencies to address the highly specific clinical needs of each age group of women, across the life cycle [3,23,24].

4. Conclusions

Based on the comprehensive analysis of international frameworks and clinical standards, several definitive conclusions can be drawn regarding the preventive role of the midwife:

Life-Course Synergy: The professional competencies of midwives are essential for executing targeted STI prevention and screening protocols across the distinct physiological and social transitions of the female reproductive lifespan.

Global Alignment: Strategic standards issued by the WHO, CDC, ICM, and FIGO reinforce the clinical and ethical necessity of anchoring midwifery practice within early health education, systematic screening, and culturally sensitive care models.

Behavioral Optimization: Applying age-appropriate health interventions and motivational interviewing effectively enhances health literacy, fosters personal accountability, and mitigates high-risk sexual behaviors among vulnerable demographic cohorts.

Epidemiological Impact: The specialized counseling skills of midwives serve as an indispensable public health tool for early risk detection, the disruption of pathogen transmission chains, and the cultivation of sustainable, protective health practices.

Sexually transmitted infections continue to pose a severe global public health challenge, driven by shifting epidemiological vectors and evolving behavioral patterns. The biological diversity and often asymptomatic nature of these pathogens demand comprehensive, proactive strategies that guarantee early detection and minimize permanent reproductive complications such as tubal infertility and oncological risks. Within this preventative infrastructure, structured midwifery counseling and health education serve as critical mechanisms for reducing risky sexual habits and fostering informed healthcare choices. Ultimately, the modernization of European regulatory requirements and educational directives formally solidifies this professional profile, positioning the autonomous midwife as a vital catalyst for protecting, promoting, and sustaining sexual and reproductive health across a woman's life course.