Global reforms in health professions education, including midwifery, support the transformation of education programmes to adopt competency-based models. Lesotho, a small sub-Saharan African country, with perennially high maternal and neonatal mortality, adopted a competency-based education model in the design and subsequent implementation of a one-year post-basic midwifery programme. Through a gap analysis involving administrators, educators and students in all the nursing education institutions in Lesotho, we explored their experiences related to the implementation of a competency-based midwifery programme after three years of continuous implementation. The findings revealed a vast gap between the described curriculum, and what was enacted in the nursing education institutions. The essential components of the midwifery programme had not been transformed to accommodate competency-based education. We argue that structural and operational elements of a programme should be adjusted before and during the implementation of such a curriculum innovation to enhance a positive teaching and learning experience, further sustaining the programme. Therefore, contextually relevant frameworks aimed at supporting the implementation and sustainability of the entire programme should be developed.