Abstract Objectives Fish is an important source of food and nutrition in Ghana. Recent epidemiological studies have reported conflicting evidence on who among urban Ghanaians consume fish, in what diet patterns fish belongs, and associations of fish consumption with nutrition outcomes. These studies have largely not differentiated between fish species in their analyses, nor have they assessed production or market sources, or variations in cooking preparations. The objectives of this qualitative study were to 1.) understand variation in fish consumption among women living in Accra across socioeconomic levels, and 2.) identify food system factors that influence variation in fish consumption. Methods We recruited a stratified convenience sample of 30 women living in low-, middle-, and high-income neighborhoods of Accra (10 women per neighborhood type), and a purposive sub-sample of 7 fisheries stakeholders (e.g., fish smokers and market vendors) (N = 37). We asked participants about their consumption and perceptions of fish, how characteristics of fisheries production and markets influence their fish consumption, and whether fish is consumed during different life stages. Interviews were conducted in the local language (Twi, Ga) or English, translated and transcribed, and hand-coded for themes and patterns using a framework analysis approach. Results Participants consumed a variety of fishes, such as mackerel, tilapia, and crab, nearly twice a day. Respondents associated fish consumption with improved health outcomes across life stages (e.g., improved nutrition during pregnancy and higher intelligence in children). Participants believed freezing and frying diminishes fish's nutritional quality, whereas smoking enhances the quality. Production sources were often cited as areas of concern (e.g., use of chemicals in fishing, open defecation at the seashore, and spoiled fish in open markets). If fish prices were too high, participants reported buying less of their preferred fish or switching to a cheaper species. Fish was highly preferred over chicken, beef, and pork. Conclusions Different components of the food system influence how women living across socioeconomic levels in Accra consume fish and perceive its role in nutrition and health. Funding Sources University of Michigan Rackham Graduate School and the International Institute.