BACKGROUND: Insecticide-treated nets (ITN) have largely been distributed via mass distribution campaigns. Since 2011, however, the World Health Organization (WHO) has recommended additional ITN distribution via routine antenatal care (ANC) and expanded programme on immunization (EPI) services. Countries have begun to implement these routine facility-based distribution strategies, but inconsistently, and there is little research on outcomes of these new programmes. This paper investigates the impact of ITN distribution policies on children's net use, comparing countries with different policies in place. METHODS: Demographic Health Surveys from 25 countries in Africa were used to analyse household ITN ownership, and ITN use among children under 5 years of age. Countries were categorized in terms of the ITN facility-based distribution policies in place, based on nationally reported policies and distribution data provided to the WHO. The analysis was conducted for individual countries and then pooled with all countries in each category weighted equally to present the average country experience, by ITN distribution policy. RESULTS: Household ITN ownership, children's ITN use, and children's ITN use in households with at least one ITN increase with each additional routine facility-based distribution policy. An average of 54.0% of children slept under an ITN in countries with ITN distribution via ANC and EPI, compared to 34.3% and 24.7% in countries with ITN distribution via ANC only, or no facility-based distribution, respectively. Linear regression found a 13% increase in net use among children under 5, on average, with each additional ITN distribution policy. CONCLUSION: ITN distribution via ANC and EPI can not only assist countries in maintaining ITN ownership and use, but may be extremely effective at increasing ITN ownership and use. There is also an additional benefit associated with combined ANC and EPI-based ITN distribution, compared to ANC distribution alone.