Little is known about the multilevel social determinants of adolescent sexual and reproductive health (SRH) that shape the use of family planning (FP) among young women in Africa. We conducted in-depth, semi-structured, qualitative interviews with 63 women aged 15–24 years in Accra and Kumasi, Ghana. We used purposive, stratified sampling to recruit women from community-based sites. Interviews were conducted in English or local languages, recorded, and transcribed verbatim. Grounded theory-guided thematic analysis identified salient themes. Three primary levels of influence emerged as shaping young women’s SRH experiences, decision-making, and behaviors. Interpersonal influences (peers, partners, and parents) were both supportive and unsupportive influences on sexual debut, contraceptive (non) use, and pregnancy resolution. Community influences included perceived norms about acceptability/unacceptability of adolescent sexual activity and its consequences (pregnancy, childbearing, abortion). Macro-social influences involved religion and abstinence and teachings about premarital sex, lack of comprehensive sex education, and limited access to confidential, quality SRH care. The willingness and ability of young women in our study to use FP methods and services were affected, often negatively, by factors operating within and across each level. These findings have implications for research, programs, and policies to address social determinants of adolescent SRH.

Adolescent pregnancy contributes to high maternal mortality rates in Sub-Saharan Africa. We explored stigma surrounding adolescent sexual and reproductive health (SRH) and its impact on young Ghanaian women’s family planning (FP) outcomes. We conducted in-depth, semi-structured interviews with 63 women ages 15-24 recruited from health facilities and schools in Accra and Kumasi, Ghana. Purposive sampling provided diversity in reproductive/relationship/socioeconomic/religious characteristics. Using both deductive and inductive approaches, our thematic analysis applied principles of grounded theory. Participants described adolescent SRH experiences as cutting across five stigma domains. First, community norms identified non-marital sex and its consequences (pregnancy, childbearing, abortion, sexually transmitted infections) as immoral, disrespectful, and disobedient, resulting in bad girl labeling. Second, enacted stigma entailed gossip, marginalization, and mistreatment from all community members, especially healthcare workers. Third, young sexually active, pregnant, and childbearing women experienced internalized stigma as disgrace, shame and shyness. Fourth, non-disclosure and secret-keeping were used to avoid/reduce stigma. Fifth, stigma resilience was achieved through social support. Collectively, SRH stigma precluded adolescents’ use of FP methods and services. Our resulting conceptual model of adolescent SRH stigma can guide health service, public health, and policy efforts to address unmet FP need and de-stigmatize SRH for young women worldwide.

When women are faced with an unplanned and unwanted pregnancy, they consult individuals in their social network whom they know have dealt with a similar situation. Misoprostol is widely available in Ghanaian cities and is successful at inducing an abortion for many women. In this way, self-inducing abortions using medication procured from pharmacists and chemical sellers has become normalised for women in Kumasi, Ghana.

Awareness of the current legal status of abortion was lacking among women with abortion-related complications attending a tertiary center in Kumasi. However, the provision of safe abortion services was much needed in this population.

Young women’s experiences with sexual and reproductive health (SRH) stigma may contribute to unintended pregnancy. Thus, stigma interventions and rigorous measures to assess their impact are needed. Based on formative work, we generated a pool of 51 items on perceived stigma around different dimensions of adolescent SRH and family planning (sex, contraception, pregnancy, child-bearing, abortion). We tested items in a survey study of 1,080 women ages 15 to 24 recruited from schools, health facilities, and universities in Ghana. Confirmatory factor analysis (CFA) identified the most conceptually and statistically relevant scale, and multivariable regression established construct validity via associations between stigma and contraceptive use. CFA provided strong support for our hypothesized Adolescent SRH Stigma Scale (chi-square p value < 0.001; root mean square error of approximation [RMSEA] = 0.07; standardized root mean square residual [SRMR] = 0.06). The final 20-item scale included three subscales: internalized stigma (six items), enacted stigma (seven items), and stigmatizing lay attitudes (seven items). The scale demonstrated good internal consistency (α = 0.74) and strong subscale correlations (α = 0.82 to 0.93). Higher SRH stigma scores were inversely associated with ever having used modern contraception (adjusted odds ratio [AOR] = 0.96, confidence interval [CI] = 0.94 to 0.99, p value = 0.006). A valid, reliable instrument for assessing SRH stigma and its impact on family planning, the Adolescent SRH Stigma Scale can inform and evaluate interventions to reduce/manage stigma and foster resilience among young women in Africa and beyond.