Abstract
<title>Abstract</title> <p>Background. Malaria remains a leading cause of maternal morbidity in Uganda, and insecticide-treated net (ITN) use during pregnancy is a cornerstone of prevention. Uganda relies on two principal ITN delivery channels universal mass distribution campaigns and routine facility-based distribution at antenatal care (ANC) and immunization clinics yet it is unclear whether the channel through which a woman receives her net shapes her subsequent likelihood of actually using it. This gap in understanding has implications for how programmes allocate resources between these two approaches. Methods. We conducted a secondary analysis of the Uganda Malaria Indicator Survey (MIS) 2024–25, a nationally representative cross-sectional survey of women aged 15–49 years. The analytic sample comprised 648 pregnant women who owned at least one ITN and had complete data on net source, net use, and selected covariates. ITN use was defined as sleeping under an ITN the preceding night. A multilevel mixed-effects logistic regression model with random intercepts at the cluster level was fitted to estimate the adjusted odds ratio (aOR) of ITN use by net source (facility-based vs. campaign-sourced), controlling for maternal age, education, wealth index, place of residence, and ANC visit frequency. Predicted probabilities of use were estimated across wealth quintiles using post-estimation marginal effects. Results. Facility-sourced nets were held by 156 women (24.1%) while 492 (75.9%) had campaign-sourced nets. In adjusted multilevel analysis, women who obtained their ITN through a health facility had more than twice the odds of sleeping under it the previous night compared to those who received it through a mass campaign (aOR 2.13; 95% CI: 1.04–4.38; p = 0.040). Advancing maternal age (aOR 1.07 per year; p = 0.003) and belonging to the richest wealth quintile (aOR 4.24; p = 0.022) were independently associated with higher ITN use. The facility-sourced advantage was most pronounced approximately eight to nine percentage points in the poorest three wealth quintiles, and narrowed among wealthier women. Conclusion. Facility-based ITN distribution, particularly through ANC services, is associated with meaningfully higher actual use among pregnant women in Uganda compared to mass campaign distribution, and this advantage is largest among the most economically disadvantaged women. These findings support reorienting programme investment toward sustained, counselling-integrated facility distribution to close the persistent gap between ITN ownership and use during pregnancy.</p>