Incidence of Nonsynostotic Plagiocephaly and Developmental Disorders.

Importance: This is the first population-based study quantifying the incidence of nonsynostotic positional plagiocephaly and/or brachycephaly (PPB) in infancy and its association with developmental disorders. Objective: To report the incidence of PPB before age 1 year, the incidence of craniosynostosis, and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years. Design, Setting, and Participants: This was a retrospective, population-based cohort study of children in the Rochester Epidemiology Project (REP) born in Olmsted County, Minnesota, from January 1, 2008, through December 31, 2012, with follow-up through age 7 years. Data were analyzed from March 2021 to April 2024. Exposure: Physical examination detecting cranial deformity. Main Outcomes and Measures: The primary outcome was the incidence of PPB. Secondary outcomes were the incidence of craniosynostosis and the percentage of children with PPB diagnosed with a developmental disorder by age 7 years. Results: Of 9909 infants (5084 [51.3%] male; 9205 [92.9%] born at term and 704 [7.1%] born preterm) included in the study, 575 had PPB, for a PPB incidence of 5.8% (95% CI, 5.3%-6.3%). The incidence of PPB was 5.3% (95% CI, 4.8%-5.8%) in term infants vs 11.8% (95% CI, 9.4%-14.6%) in preterm infants. The incidence of craniosynostosis was 0.16% (95% CI, 0.09%-0.26%). A developmental disorder was known or suspected in 4.2% (95% CI, 2.7%-6.2%) of infants at the time of PPB diagnosis; among 402 infants with PPB and follow-up through age 7 years, 30 (7.5%; 95% CI, 5.0%-10.7%) had a confirmed developmental disorder by 7 years of age. The prevalence of autism spectrum disorder (ASD) in children with a history of PPB who were followed up to age 7 years was 2.2% (9 of 402 children). Conclusions and Relevance: This study found that only a small percentage of the infants had positional head deformity significant enough to be documented and/or referred for subspecialty evaluation, and only a small subset of these children went on to have a developmental disorder in childhood. This information is helpful for counseling families about their child's developmental risk at time of PPB diagnosis.

Adaptive selection at G6PD and disparities in diabetes complications.

Diabetes complications occur at higher rates in individuals of African ancestry. Glucose-6-phosphate dehydrogenase deficiency (G6PDdef), common in some African populations, confers malaria resistance, and reduces hemoglobin A1c (HbA1c) levels by shortening erythrocyte lifespan. In a combined-ancestry genome-wide association study of diabetic retinopathy, we identified nine loci including a G6PDdef causal variant, rs1050828 -T (Val98Met), which was also associated with increased risk of other diabetes complications. The effect of rs1050828 -T on retinopathy was fully mediated by glucose levels. In the years preceding diabetes diagnosis and insulin prescription, glucose levels were significantly higher and HbA1c significantly lower in those with versus without G6PDdef. In the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, participants with G6PDdef had significantly higher hazards of incident retinopathy and neuropathy. At the same HbA1c levels, G6PDdef participants in both ACCORD and the Million Veteran Program had significantly increased risk of retinopathy. We estimate that 12% and 9% of diabetic retinopathy and neuropathy cases, respectively, in participants of African ancestry are due to this exposure. Across continentally defined ancestral populations, the differences in frequency of rs1050828 -T and other G6PDdef alleles contribute to disparities in diabetes complications. Diabetes management guided by glucose or potentially genotype-adjusted HbA1c levels could lead to more timely diagnoses and appropriate intensification of therapy, decreasing the risk of diabetes complications in patients with G6PDdef alleles.

Codesign and refinement of an optimised antenatal education session to better inform women and prepare them for labour and birth.

OBJECTIVE: Our objective was to codesign, implement, evaluate acceptability and refine an optimised antenatal education session to improve birth preparedness. DESIGN: There were four distinct phases: codesign (focus groups and codesign workshops with parents and staff); implementation of intervention; evaluation (interviews, questionnaires, structured feedback forms) and systematic refinement. SETTING: The study was set in a single maternity unit with approximately 5500 births annually. PARTICIPANTS: Postnatal and antenatal women/birthing people and birth partners were invited to participate in the intervention, and midwives were invited to deliver it. Both groups participated in feedback. OUTCOME MEASURES: We report on whether the optimised session is deliverable, acceptable, meets the needs of women/birthing people and partners, and explain how the intervention was refined with input from parents, clinicians and researchers. RESULTS: The codesign was undertaken by 35 women, partners and clinicians. Five midwives were trained and delivered 19 antenatal education (ACE) sessions to 142 women and 94 partners. 121 women and 33 birth partners completed the feedback questionnaire. Women/birthing people (79%) and birth partners (82%) felt more prepared after the class with most participants finding the content very helpful or helpful. Women/birthing people perceived classes were more useful and engaging than their partners. Interviews with 21 parents, a midwife focus group and a structured feedback form resulted in 38 recommended changes: 22 by parents, 5 by midwives and 11 by both. Suggested changes have been incorporated in the training resources to achieve an optimised intervention. CONCLUSIONS: Engaging stakeholders (women and staff) in codesigning an evidence-informed curriculum resulted in an antenatal class designed to improve preparedness for birth, including assisted birth, that is acceptable to women and their birthing partners, and has been refined to address feedback and is deliverable within National Health Service resource constraints. A nationally mandated antenatal education curriculum is needed to ensure parents receive high-quality antenatal education that targets birth preparedness.

Nature-based social prescribing programmes: opportunities, challenges, and facilitators for implementation.

BACKGROUND: Evidence on the health benefits of spending time in nature has highlighted the importance of provision of blue and green spaces where people live. The potential for health benefits offered by nature exposure, however, extends beyond health promotion to health treatment. Social prescribing links people with health or social care needs to community-based, non-clinical health and social care interventions to improve health and wellbeing. Nature-based social prescribing (NBSP) is a variant that uses the health-promoting benefits of activities carried out in natural environments, such as gardening and walking. Much current NBSP practice has been developed in the UK, and there is increasing global interest in its implementation. This requires interventions to be adapted for different contexts, considering the needs of populations and the structure of healthcare systems. METHODS: This paper presents results from an expert group participatory workshop involving 29 practitioners, researchers, and policymakers from the UK and Germany's health and environmental sectors. Using the UK and Germany, two countries with different healthcare systems and in different developmental stages of NBSP practice, as case studies, we analysed opportunities, challenges, and facilitators for the development and implementation of NBSP. RESULTS: We identified five overarching themes for developing, implementing, and evaluating NBSP: Capacity Building; Accessibility and Acceptability; Networks and Collaborations; Standardised Implementation and Evaluation; and Sustainability. We also discuss key strengths, weaknesses, opportunities, and threats for each overarching theme to understand how they could be developed to support NBSP implementation. CONCLUSIONS: NBSP could offer significant public health benefits using available blue and green spaces. We offer guidance on how NBSP implementation, from wider policy support to the design and evaluation of individual programmes, could be adapted to different contexts. This research could help inform the development and evaluation of NBSP programmes to support planetary health from local and global scales.

Cross Sectional Survey of Antenatal Educators' Views About Current Antenatal Education Provision.

OBJECTIVES: Antenatal education (ANE) is part of National Health Service (NHS) care and is recommended by The National Institute for Health and Care Excellence (NICE) to increase birth preparedness and help pregnant women/birthing people develop coping strategies for labour and birth. We aimed to understand antenatal educator views about how current ANE supports preparedness for childbirth, including coping strategy development with the aim of identifying targets for improvement. METHODS: A United Kingdom wide, cross-sectional online survey was conducted between October 2019 and May 2020. Antenatal educators including NHS midwives and private providers were purposively sampled. Counts and percentages were calculated for closed responses and thematic analysis used for open text responses. RESULTS: Ninety-nine participants responded, 62% of these did not believe that ANE prepared women for labour and birth. They identified practical barriers to accessing ANE, particularly for marginalised groups, including financial and language barriers. Educators believe class content is medically focused, and teaching is of variable quality with some midwives being ill-prepared to deliver antenatal education. 55% of antenatal educators believe the opportunity to develop coping strategies varies between location and educators and only those women who can pay for non-NHS classes are able to access all the coping strategies that can support them with labour and birth. CONCLUSIONS FOR PRACTICE: Antenatal educators believe current NHS ANE does not adequately prepare women for labour and birth, leading to disparities in birth preparedness for those who cannot access non-NHS classes. To reduce this healthcare inequality, NHS classes need to be standardised, with training for midwives in delivering ANE enhanced.

Exploring a career pathway for home support workers in Ireland: a systematic scoping review of the international evidence.

Background: In prosperous nations like Ireland, home support workers (HSWs) play an increasingly vital role in providing person-centred care to ageing populations. However, challenges such as workforce shortages, role ambiguity, low pay, and limited career advancement, hinder workforce development and career building. Method: A scoping review using key terms for "HSWs" and "career pathways" was conducted following the Joanna Briggs Institute Methodology, examining electronic databases (Web of Science, PubMed, MEDLINE, EMBASE, CINAHL, PscyINFO, Social Care Online, Social Sciences Citation Index). Inclusion criteria were applied, and a thematic analysis followed and inductive-deductive approach. Results: The review encompassed 261 relevant articles from different countries. Four key themes were identified: (1) Data-driven decision-making on the future workforce, (2) Attracting and developing a competent and motivated home support workforce, (3) Enhancing working lives and retention at every stage of career pathways, and (4) Crafting career pathways to improve quality and impact. Discussion: Leadership, collaboration, and data-driven decision-making across policy, research and practice are pivotal for expanding and enhancing home support. Emphasising a shift towards preventative self-management models, supported by digitally skilled and regulated HSWs, could enhance independence and quality of care. Clear career structures, professional development, and inclusive organisational environments are essential to attract, retain, and empower a competent and motivated workforce, fostering quality and impact. Conclusion: This scoping review provides foundational evidence to establish career pathways for HSWs, identifying key areas for development such as data collection, care model transformation, career progression structures, and systems for safety and quality improvement.

Gabapentin as part of a multimodal pain protocol for selective dorsal rhizotomy does not impact percentage of rootlets transected.

PURPOSE: We aim to determine whether preoperatively initiated gabapentin for pain control impacts the percentage of rootlets cut during monitored, limited laminectomy selective dorsal rhizotomy (SDR) procedure. METHODS: This retrospective cohort study includes participants with cerebral palsy who had SDR for treatment of spasticity between 2010 and 2019 at a single-institution tertiary care center. One-level laminectomy SDR aimed to evaluate the cauda equina roots from levels L2-S1 with EMG monitoring. Gabapentin titration began 3 weeks prior to SDR. Data was analyzed using simple linear regression. Thirty-one individuals met inclusion criteria. Mean age was 7 years, 4 months. Eighteen participants (58%) identified as male, 12 (39%) female, and one (3%) non-binary. Thirty (97%) had bilateral CP. Sixteen (52%) were GMFCS II, four (13%) GMFCS III, five (16%) GMFCS IV, and six (19%) GMFCS V. RESULTS: Mean percentage of rootlets transected was 50.75% (SD 6.00, range 36.36-60.87). There was no relationship between the dose of gabapentin at time of SDR and percentage of rootlets cut with a linear regression slope of - 0.090 and an R2 of 0.012 (P = 0.56). CONCLUSION: Results indicate that preoperative initiation of gabapentin did not impact the percentage of rootlets transected. Thus, gabapentin can be initiated prior to SDR at moderate dosages without impacting SDR surgical outcomes.

Development of Portable Electronic Health Record Based Algorithms to Identify Individuals with Diabetic Retinopathy.

Objectives: To develop, validate and implement algorithms to identify diabetic retinopathy (DR) cases and controls from electronic health care records (EHR)s. Methods : We developed and validated EHR-based algorithms to identify DR cases and individuals with type I or II diabetes without DR (controls) in three independent EHR systems: Vanderbilt University Medical Center Synthetic Derivative (VUMC), the VA Northeast Ohio Healthcare System (VANEOHS), and Massachusetts General Brigham (MGB). Cases were required to meet one of three criteria: 1) two or more dates with any DR ICD-9/10 code documented in the EHR, or 2) at least one affirmative health-factor or EPIC code for DR along with an ICD9/10 code for DR on a different day, or 3) at least one ICD-9/10 code for any DR occurring within 24 hours of an ophthalmology exam. Criteria for controls included affirmative evidence for diabetes as well as an ophthalmology exam. Results: The algorithms, developed and evaluated in VUMC through manual chart review, resulted in a positive predictive value (PPV) of 0.93 for cases and negative predictive value (NPV) of 0.97 for controls. Implementation of algorithms yielded similar metrics in VANEOHS (PPV=0.94; NPV=0.86) and lower in MGB (PPV=0.84; NPV=0.76). In comparison, use of DR definition as implemented in Phenome-wide association study (PheWAS) in VUMC, yielded similar PPV (0.92) but substantially reduced NPV (0.48). Implementation of the algorithms to the Million Veteran Program identified over 62,000 DR cases with genetic data including 14,549 African Americans and 6,209 Hispanics with DR. Conclusions/Discussion: We demonstrate the robustness of the algorithms at three separate health-care centers, with a minimum PPV of 0.84 and substantially improved NPV than existing high-throughput methods. We strongly encourage independent validation and incorporation of features unique to each EHR to enhance algorithm performance for DR cases and controls.

Petechial Rash and Glomerulonephritis: First Presentation of Endocarditis on a Patent Foramen Ovale Closure Device.

Patent foramen ovale device closure is rarely associated with complications. This case report is believed to be the first description of a patient with infective endocarditis of a patent foramen ovale closure device presenting as glomerulonephritis. This article serves to educate as to this rare device complication and its unusual presentation. (Level of Difficulty: Intermediate.).

Prospects and Aspirations for Workforce Training and Education in Social Prescribing.

BACKGROUND: A social prescribing (SP) link worker (LW) is responsible for enabling and supporting individuals, by assessing their personal goals and co-producing solutions to make use of appropriate local non-clinical resources or interventions. As an emerging new role, LWs are not regulated by professional bodies associated with SP. Therefore, currently there is no standardised training for LWs who are from varied backgrounds. As such, LWs have varying knowledge about how to deal with individuals with complex needs, which can impact on their decision-making capabilities to seek solutions and navigate complex systems. The purpose of the research was to explore LWs' level of education, past and current training requirements as well as elicit how much LWs were willing to pay (WTP) to access and undertake training to improve their skill set. METHODS: A rigorous mixed method research design was employed which included semi-structured interviews with key stakeholders and quantitative questionnaires including contingent valuation (CV) questions to a population of LWs across Wales from March to June 2020. Qualitative interviews with key stakeholders who commission and deliver social prescribing interventions employing LWs identified perceived link worker qualities and requirements for LW roles. Purposive sampling was used to identify and select individuals that have experience in managing LWs. Due to the COVID-19 pandemic, interviews were carried out exclusively online. LWs self-selected to complete the online questionnaires. Questionnaires gathered data on LW qualifications and demographic information with the CV questions gathering data on the value LW placed on accessing training in SP. Thematic narrative analysis was applied to interpret the data from the semi-structured interviews. Descriptive frequency analysis was conducted on the quantitative data generated from the online questionnaire. FINDINGS: SP coordinators (n = 6) reported that 'personal skills' are the most essential skills required by LWs in SP intervention. Training is available for LWs; however, the training undertaken varies depending on the type of intervention delivered, with 70% of LWs previously undertaking training to facilitate their development as an LW. The results from the contingent valuation questionnaire (n = 54) indicated that 100% of the respondents would avail of training. LWs were asked how much they were willing to pay as a single payment for professional training; on average, LWs were WTP GBP 58 from their personal funds to access training and the associated benefits to enhance their skills and knowledge. INTERPRETATION: The semi-structured interviews conducted with the key SP stakeholders yielded rich information and novel insight into LW training. External funding for the salary of the LW is an obstacle for LW development through training. In addition, the questionnaire results regarding stated preference techniques demonstrate that LWs place value on their professional development and would be willing to spend their own money on training to improve their knowledge and skills.

Social Return on Investment of Social Prescribing via a Diabetes Technician for Preventing Type 2 Diabetes Progression.

In Wales, the prevalence of Type 2 Diabetes Mellitus (T2DM) has increased from 7.3% in 2016 to 8% in 2020, creating a major concern for the National Health Service (NHS). Social prescribing (SP) has been found to decrease T2DM prevalence and improve wellbeing. The MY LIFE programme, a scheme evaluated between June 2021 and February 2022 in the Conwy West Primary Care Cluster, aimed to prevent T2DM by referring prediabetic patients with a BMI of ≥30 to a diabetes technician (DT), who then signposted patients to community-based SP programmes, such as the National Exercise Referral Scheme (NERS), KindEating, and Slimming World. Although some patients engaged with SP, others chose to connect only with the DT. A Social Return on Investment (SROI) analysis was conducted to evaluate those patients who engaged with the DT plus SP, and those who connected solely with the DT. Relevant participant outcomes included 'mental wellbeing' and 'good overall health', which were measured at baseline (n = 54) and at the eight-week follow-up (n = 24). The estimated social value for every GBP 1 invested for participants who engaged with the 'DT only' ranged from GBP 4.67 to 4.70. The social value for participants who engaged with the 'DT plus SP programme' ranged from GBP 4.23 to 5.07. The results indicated that most of the social value generated was associated with connecting with the DT.

Prevention of Poor Physical and Mental Health through the Green Social Prescribing Opening Doors to the Outdoors Programme: A Social Return on Investment Analysis.

There is growing interest in green social prescribing and connecting with nature-based activities to promote social cohesion along with improving levels of health, wealth and well-being. The Outdoor Partnership is a third sector organisation based in North Wales offering nature based social prescribing interventions. Individuals experiencing poor mental health and wellbeing are referred from GPs, community mental health services, and third sector organisations to the 'Opening the Doors to the Outdoors' (ODO) programme which is a 12-week outdoor walking and climbing green prescribing intervention. The purpose of the ODO programme is to provide a supportive environment to increase levels of physical activity among participants leading to improvements in overall health and mental wellbeing while promoting socialisation among peers. In this evaluation of a preventative green social prescribing intervention, a mixed method social return on investment (SROI) approach used quantitative and qualitative data from ODO participants. Data collection took place from April 2022-November 2022. Mental wellbeing data was collected at baseline and at 12 weeks using the Short Warwick Edinburgh Mental Wellbeing Scale, a social trust question, an overall health question, and the International Physical Activity Questionnaire- short form. Baseline and follow-up data was available for 52 ODO participants. Results indicate that for every £1 invested in the ODO programme, social values ranging from £4.90 to £5.36 were generated.

Exploring current nutritional programming and resources available to people living with HIV in Canada: a scoping review.

OBJECTIVE: The objective of this scoping review was to map the current literature and resources available on nutrition and food programming for people living with HIV in Canada. This review is phase 1 of a 4-phase project, called FoodNOW (Food to eNhance Our Wellness), a community-based nutritional needs assessment of people living with HIV in Nova Scotia, Canada. INTRODUCTION: People living with HIV may experience nutritional challenges, including nutritional deficiencies associated with the virus, food insecurity, and nutrition-drug interactions. Nutritional programming is often required for optimal care for people living with HIV. The literature, however, has not been sufficiently mapped to create a comprehensive picture of available programming. This review has informed the development of subsequent study phases, and will contribute towards shaping and planning food programs, as well as evaluating the need for subsequent systematic reviews. INCLUSION CRITERIA: This review considered literature focused on nutrition and food programming and resources in Canada for people living with HIV. People living with HIV of any age, sex, race, gender identity, or sexual orientation, as well as pregnant and lactating people, were included as the population of interest. METHODS: The databases searched were MEDLINE (Ovid), CINAHL (EBSCO), Academic Search Premier (EBSCO), Social Services Abstracts (ProQuest), and Scopus. Sources of gray literature searched included government and organization websites, and Google searches. The database search was conducted in July 2021, and the gray literature searches were conducted in August and October 2021. Searches were limited to evidence published or translated in English. Two independent reviewers conducted title and abstract screening, and potentially relevant results were retrieved in full. Full-text screening and data extraction was conducted by 2 independent reviewers using a data extraction tool designed specifically for the scoping review objectives and research inclusion criteria, and any conflicts were resolved through discussion. Results are presented in both tabular and diagrammatic formats, with a narrative summary. RESULTS: A total of 581 results were screened (published and gray literature). A total of 64 results were included in the review. The 6 reasons for exclusion at full-text review were i) not nutrition and food programming (n= 83), ii) not Canadian (n= 37), iii) duplicates (n= 22), iv) not focused on people living with HIV (n= 6), v) conference abstract (n= 1), and vi) not in English (n= 1). A total of 76 resources were located, as some of the 64 included sources offered more than 1 resource. The 76 resources were organized into 6 categories: i) charitable food provision (n = 21; 27.6%), ii) financial aid (n = 14; 18.4%), iii) nutrition care (n =12; 15.8%), iv) providing access to secondary sources (n= 10; 13.2%), v) food and nutrition expertise (n= 10; 13.2%), and vi) population health promotion (n= 9; 11.8%). Recommendations for future research and programming are discussed. CONCLUSIONS: This scoping review demonstrates that current programming relies heavily on charitable food provision services for people living with HIV and that there is an unequal distribution of resources across Canada. Program expansion to target diverse populations with more equal distribution across Canada may improve overall health outcomes for people living with HIV. Future research is needed to evaluate the effectiveness of available programming and the needs of end users (people living with HIV and their supports). FoodNOW will build on these findings to further explore and address the needs of people living with HIV. REVIEW REGISTRATION: Open Science Framework https://osf.io/97x3r.

The Cost of a Nutritious Diet for Households Including People Living with HIV/AIDS in Nova Scotia: Findings and Lessons Learned by FoodNOW 2020 to 2022.

Purpose: FoodNOW (Food to eNhance Our Wellness) engaged in assessment of simulated households that include a person living with HIV/AIDS (PLWHA) in Nova Scotia to determine if a basic nutritious diet is affordable.Methods: We used supermarket websites to cost food and beverage items listed in the National Nutritious Food Basket (NNFB) for simulated households, each with a PLWHA. Food costing methodologies were co-developed and adapted with community members in response to barriers presented by the COVID-19 pandemic.Results: We found that simulated households, each with one PLWHA, that had a potential deficit after monthly expenses were a household of four on Income Assistance (-$1,058.70), a lone mother with two children on Income Assistance (-$973.65), a lone man on Income Assistance (-$677.40), and a household of four with one minimum-wage earner (-$383.45).Conclusions: Nova Scotia households with a PLWHA living on Income Assistance or with a minimum-wage earner cannot reasonably afford a nutritious diet in addition to basic household expenses. Using these food costing data can allow dietitians to efficiently inform government action and policy change to improve the health and wellness of individuals and families.

Effects of Protein Supplementation Strategy and Genotype on Milk Production and Nitrogen Utilisation Efficiency in Late-Lactation, Spring-Calving Grazing Dairy Cows.

The objectives of this study were to evaluate the effects of (1) protein supplementation strategy, (2) cow genotype and (3) an interaction between protein supplementation strategy and cow genotype on milk production and nitrogen (N) utilisation efficiency (milk N output/ total dietary N intake × 100; NUE) in late-lactation, spring-calving grazing dairy cows. A 2 × 2 factorial arrangement experiment, with two feeding strategies [13% (lower crude protein; LCP) and 18% CP (higher CP; HCP) supplements with equal metabolisable protein supply] offered at 3.6 kg dry matter/cow perday, and two cow genotype groups [lower milk genotype (LM) and higher milk genotype (HM)], was conducted over 53 days. Cows were offered 15 kg dry matter of grazed herbage/cow/day. Herbage intake was controlled using electric strip wires which allowed cows to graze their daily allocation-only. There was an interaction for herbage dry matter intake within cows offered HCP, where higher milk genotype (HM) cows had increased herbage dry matter intake (+0.58 kg) compared to lower milk genotype (LM) cows. Offering cows LCP decreased fat + protein yield (-110 g) compared to offering cows HCP. Offering cows LCP decreased the total feed N proportion that was recovered in the urine (-0.007 proportion units) and increased the total feed N proportion that was recovered in the faeces (+0.008 proportion units) compared to offering cows HCP. In conclusion, our study shows that reducing the supplementary CP concentration from 18% to 13% resulted in decreased milk production (-9.8%), reduced partitioning of total feed N to urine (-0.9%) and increased partitioning of total feed N to faeces (+14%) in late lactation, grazing dairy cows.

Antenatal care in Nepal: a qualitative study into missed opportunities in the first trimester.

BACKGROUND: Use of timely antenatal care has been identified as key to facilitating healthy pregnancies worldwide. Although considerable investment has been made to enhance maternal health services in Nepal, approximately one-third of women do not attend antenatal care until after the first trimester (late). These women miss out on the benefits of screening and interventions that are most effective in the first trimester. OBJECTIVE: This study aimed to identify the missed opportunities of women who do not attend antenatal care in the first trimester, and to explore some of the factors underlying late attendance and consider potential solutions for minimizing these missed opportunities in the future. STUDY DESIGN: This study was conducted in 3 hospitals in Nepal. Focus groups (n=18) with a total of 48 postnatal women and 49 staff members, and 10 individual interviews with stakeholders were conducted. Purposive sampling facilitated the obtainment of a full range of maternity experiences, staff categories, and stakeholder positions. Data were qualitative and analyzed using a thematic approach. RESULTS: Limited awareness among women of the importance of early antenatal care was reported as a key factor behind attendance only after the first trimester. The family and community were described as significant influencers in women's decision-making regarding the timing of antenatal care. The benefits of early ultrasound scanning and effective supplementation in pregnancy were the major missed opportunities. Increasing awareness, reducing cost, and enhancing interprofessional collaboration were suggested as potential methods for improving timely initiation of antenatal care. CONCLUSION: Limited awareness continues to drive late attendance to antenatal care after the first trimester. Investment in services in the first trimester and community health education campaigns are needed to improve this issue and enhance maternal and neonatal outcomes.