Age, Access, and Autonomy: Self-Managed Medical Abortions Among Adolescents and Young Women in Ghana

Medical abortion (MA) is increasingly accessed and managed outside formal health settings across sub-Saharan Africa, yet little is known about how age shapes sourcing decisions or the experiences that follow. In Ghana, where pharmacy dispensing without prescription is common despite legal restrictions, this gap has direct implications for ongoing abortion policy reform. This dissertation examines pharmacy-sourced self-managed abortion (SMA) among adolescents and young women across four regions in Ghana using a mixed-methods approach and drawing on abortion trajectories and person-centered care frameworks.Aim 1 used secondary data from 1,975 women seeking MA, to examine factors associated with pharmacy-sourced MA as a proxy for SMA, and age as an effect modifier. Logistic regression identified associations between pharmacy sourcing and education, reproductive history, information channels, and reasons for source selection. Age modified associations with personal information channels and convenience- and quality -based source selection. The magnitude of these associations varied by age, with personal information channels more strongly linked to pharmacy sourcing among young women, and convenience-based selection more strongly linked among older women, while quality-based concerns were inversely linked to pharmacy sourcing more strongly among older women.Aim 2 analyzed in-depth interviews with 23 adolescents aged 16–19 obtaining MA from pharmacies and clinics within the same parent trial. Thematic analysis identified constrained pathways shaped by limited information, stigma, provider attitudes, and financial barriers. Adolescents navigated care in secrecy with little support, often selecting sources in response to structural and interpersonal obstacles rather than preferences. Care was frequently fragmented across settings, with limited guidance during home management and inadequate follow-up care.Together, the two aims demonstrate that adolescents and young women in Ghana navigate abortion pathways under structural constraints and social stigma, with age shaping both the trajectories and the factors driving source selection. Across both clinic and pharmacy settings, care was fragmented and often fell short of person-centered standards, particularly during home management and follow-up. Findings point to the need for both universal and age-responsive interventions that address information gaps, reduce stigma, and improve person-centered care quality across settings and care models.