Continuing Professional Development (CPD) is a cornerstone of lifelong learning for nurses and midwives, essential for maintaining competence, improving patient outcomes, and meeting regulatory requirements [1]. In Zambia, the Nursing and Midwifery Council of Zambia (NMCZ) mandates that all registered midwives earn a minimum of 20 CPD points annually and submit evidence of these activities prior to licence renewal [2]. Despite this regulatory framework and awareness campaigns conducted since 2014, a significant proportion of midwives fail to comply. At the Women and Newborn University Teaching Hospital (WNH-UTH) in Lusaka, an average of 55% of midwives submitted their CPD records late between 2021 and 2024, and an additional 9% did not submit at all [3].

Across sub-Saharan Africa, low participation in mandatory CPD among nurses and midwives has been attributed to a range of systemic and individual barriers. Studies from Ethiopia, for example, show that nurses’ engagement in CPD remains low (34.4%), with financial and time constraints along with limited access to information and resources, significantly hindering participation [4][5]. In Namibia, time constraints, staff shortages, limited access to digital technologies, lack of funding for CPD, and a shortage of accredited CPD service providers are major barriers to nurses’ compliance with CPD requirements [6]. A multi-country qualitative evaluation in Malawi, Tanzania and South Africa similarly identified lack of sustainable financial resources, limitations in CPD coordination, healthcare worker shortages, and a mismatch between CPD offerings and practitioners’ needs as key obstacles [7]. In Rwanda, while 97.3% of nurses and midwives recognised the importance of CPD, procedural and technological barriers including limited practical knowledge about CPD implementation, curtailed their engagement [8]. A scoping review of CPD programmes across African hospitals further confirmed that financial constraints, staff shortages, inequitable training selection, and infrastructural limitations for e-learning are the most pervasive barriers to effective CPD implementation [9]. Beyond nurses and midwives, similar barriers such as cost, workload, location, rostering, lack of employer support and technological problems, have been documented among other healthcare cadres in Africa, such as radiographers in Malawi [10].

While these studies have collectively mapped the landscape of CPD challenges, much of the existing literature has focused on broad structural and resource-related barriers such as funding deficits, staffing shortages, and access to training opportunities, rather than on the role of practitioners’ knowledge of the CPD process itself. A critical prerequisite for CPD compliance is accurate knowledge of the programme’s requirements, governance, and procedures. Without accurate knowledge, midwives cannot navigate the system effectively, irrespective of their motivation. Yet, few studies have systematically examined the depth and accuracy of healthcare workers’ knowledge of the CPD process, and even fewer have quantitatively tested whether such knowledge independently predicts participation. In Zambia, no prior study has systematically assessed midwives’ knowledge of the CPD process, nor has the link between such knowledge and actual participation been empirically examined. The persistent low submission rates at WNH-UTH, despite regulatory efforts, point to the possibility that fundamental knowledge gaps are undermining participation, but this hypothesis has not been tested.

This study therefore aimed to: 1) assess the level of knowledge of the CPD process among midwives at WNH-UTH; and 2) determine whether knowledge is significantly associated with CPD participation. By isolating knowledge as a potential key lever, a dimension largely overlooked in prior barrier-focused research, the findings are intended to inform targeted educational and policy interventions that can improve CPD uptake.

This study aimed to assess midwives’ knowledge of the CPD process at a major Zambian tertiary hospital and to determine whether that knowledge influences their participation. The findings show that only 44.3% of midwives had participated in CPD and submitted their evidence for licence renewal—a figure strikingly similar to the 34.4% CPD engagement rate reported among nurses in Ethiopia [4]. In the multivariable analysis, adequate knowledge emerged as the only measured factor significantly associated with participation, with 2.44-fold higher odds of engagement. This suggests that, in this dataset and setting, knowledge of how the CPD system works is a key gateway to compliance.

Importantly, while 79.3% of midwives achieved an overall adequate knowledge score, item level analysis revealed substantial functional gaps. Three quarters of respondents incorrectly believed that the NMCZ is the sole manager of the CPD programme, and half thought CPD points can be submitted at any time. These gaps in procedural and governance knowledge mirror findings from a multi country qualitative evaluation in Malawi, Tanzania and South Africa, where healthcare workers often understood the CPD mandate but struggled with accreditation processes and submission timelines [7]. In Rwanda, similarly, Nyiringango et al. [8] found that practical knowledge about CPD implementation lagged behind positive attitudes, a phenomenon that appears to repeat itself in Zambia.

The strong, independent association between knowledge and participation, with no demographic or professional characteristic reaching significance in the final model, suggests that the primary barriers to CPD uptake in this context are not intrinsic to individual midwives but are embedded in the information environment. This interpretation aligns with a systematic review by Merry et al. [5], which noted that in low and lower middle-income countries, weak dissemination of CPD information and lack of clarity about governance often undermine participation even when regulations exist. Likewise, a study in Meru County, Kenya, found that knowledge gaps in clinical competencies directly affected CPD uptake and clinical performance, reinforcing the notion that accurate information is a prerequisite for meaningful engagement [14].

Across sub–Saharan Africa, low CPD engagement is a persistent challenge. A review of CPD status in WHO Afro region member states identified inequity of CPD distribution, healthcare worker shortages, and limited participation as major threats [15]. In Zambia specifically, access to CPD resources, including laptops, reliable internet, and structured learning opportunities, has been described as “one of the main challenges for Zambian nurses”, with many activities conducted via smartphones and limited IT access constraining the quality and reach of CPD [16]. An Ethiopian study by Wehabe et al. [4] further identified financial constraints (AOR 3.1), lack of access to CPD information (AOR 0.3), time constraints due to family commitments (AOR 3.35), and insufficient CPD resources (AOR 0.15) as significant predictors of low engagement. Although these specific barriers were not measured in the present study, they likely operate in the Zambian context as well and may help explain why even midwives with adequate knowledge still struggle to participate.

Taken together, these regional comparisons suggest that knowledge alone is rarely sufficient. Even when information is accurate, practical obstacles, such as heavy clinical workloads, limited financial support for training, lack of employer provided CPD opportunities, and unsupportive management, can prevent midwives from converting knowledge into action [4][7]. This multi layered reality is reflected in a qualitative study in Kenya, where nurses reported that simply providing CPD opportunities does not guarantee participation; tailored efforts are needed to dismantle institutional and external barriers [17]. Similarly, a study on CPD access for emergency obstetric and neonatal care providers in Rwanda highlighted that even when midwives recognised the value of CPD, inadequate infrastructure and limited programme availability restricted their actual uptake [18].

The finding that no demographic or job related variable predicted participation is, in itself, instructive. It suggests that the factors driving CPD compliance are not “who you are” but rather “what you know” and, by extension, “what systems and supports are in place”. This is consistent with the work of Mlambo et al. [1], who emphasised that a supportive learning environment, including clear communication and accessible resources, is essential for CPD participation. In the Zambian context, a national leadership and management CPD programme for frontline nurses and midwives has shown that blended learning can be effective when accompanied by institutional commitment and structured mentorship [19]. Such models could be adapted to address the specific knowledge gaps identified in the present study.

These findings have direct and urgent implications for policy and practice. The NMCZ and health facility managers must move beyond general awareness campaigns and focus on building comprehensive, functional knowledge. Educational interventions should specifically address the misconceptions identified: the multi-stakeholder nature of CPD governance, the strict submission timeline, and the procedural steps for earning and recording points. Integrating simple, visually engaging job aids, mandatory in-service orientation sessions, and structured mentorship programmes could help bridge the knowledge gap. Furthermore, hospital management should take proactive responsibility for disseminating accurate, timely CPD information, rather than relying solely on the NMCZ. The regression results also hint, though not statistically significant, that certain job cadres may have higher odds of participation, which warrants further investigation with larger samples.

The limitations of this study should be acknowledged. The cross-sectional design cannot establish causality; it is possible that participation in CPD also reinforces knowledge, creating a bidirectional relationship. The single-site setting limits the generalizability of the findings to other facilities, although WNH-UTH is typical of large public tertiary hospitals in Zambia. The measurement of participation relied on self-report, which may be subject to recall or social desirability bias. Nonetheless, the high response rate and the robust multivariable analysis strengthen confidence in the primary finding. More importantly, this study measured only a limited set of barriers—primarily knowledge. It did not capture key contextual factors such as workload, access to CPD opportunities, cost, managerial support, or the availability of IT resources. These unmeasured barriers are likely to play a substantial role in shaping actual participation and should be investigated in future mixed methods and multi-site research.

In a setting where CPD is legally required but compliance is low, midwives’ knowledge of the CPD process, as the only measured factor, showed a significant association with CPD participation. While this finding highlights the importance of accurate information, it does not mean that other factors are unimportant. Unmeasured barriers such as heavy clinical workloads, limited access to affordable CPD opportunities, personal costs, and the level of managerial support, may also play a substantial role in shaping whether midwives engage with CPD. Therefore, improving knowledge alone is unlikely to be a complete solution. Efforts to strengthen CPD uptake should combine targeted education with broader strategies that address the practical and systemic challenges midwives face in their daily work.

The authors sincerely thank the midwives at the Women and Newborn University Teaching Hospital for their participation. We also acknowledge the hospital management and the NMCZ for facilitating data collection.