A Multilevel Analysis of the Association Between Quality of Antenatal Care and Folic Acid Supplementation During Pregnancy Among Guatemalan Women

<b>Background:</b> Folic acid supplementation during pregnancy is essential for preventing neural tube defects and other congenital anomalies. Despite global recommendations, supplementation remains suboptimal in many low- and middle-income countries, including Guatemala, where disparities persist across regions and populations. <b>Objective:</b> To investigate the association between the quality of antenatal care and folic acid supplementation among pregnant women in Guatemala. <b>Design and Setting:</b> This cross-sectional study used data from the 2014-2015 Encuesta Nacional de Salud Materno Infantil (ENSMI), part of the Demographic and Health Survey (DHS). A total of 9523 women aged 15-49 with children under two years were included. Folic acid supplementation was assessed through self-reported responses to survey questions. Multilevel logistic regression examined the association between antenatal care quality and folic acid supplementation, accounting for individual, household, and community-level factors. <b>Results:</b> Overall, 15.4% of women reported not taking folic acid during pregnancy. Lower folic acid supplementation was most notable among women who received no or inadequate antenatal care, indigenous women, and those living in socioeconomically disadvantaged communities. Women without antenatal care had 97% lower odds of folic acid supplementation compared with those with adequate care (OR = 0.03, 95% CI: 0.02-0.04, and <i>p</i> < 0.001), while intermediate care was associated with 41% lower odds (OR = 0.59, 95% CI: 0.47-0.74, and <i>p</i> < 0.001). Indigenous women had 26% lower odds of supplementation (OR = 0.74, 95% CI: 0.63-0.86, and <i>p</i> < 0.001), and women in communities with high levels of no media exposure had 33% lower odds of folic acid supplementation (OR = 0.67 and 95% CI: 0.53-0.84). <b>Conclusions:</b> Quality antenatal care plays a critical role in improving maternal nutrition behaviors. These findings underscore the need for targeted interventions, such as culturally tailored education, mass media campaigns, and improved access to antenatal careto increase folic acid supplementation among pregnant women in Guatemala.