Background: Sierra Leone has high maternal mortality. Socio-ecological factors are considered contributing factors to this high mortality. Anemia is considered to be a direct cause of 4% of maternal deaths and an indirect cause of 20-40% of maternal deaths. Purpose: The current study explores socio-ecological contributing factors to the anemia status of 171 pregnant Sierra Leone women. Methods: A structured questionnaire framed around the Modified Ecological Model for Health Behavior and Health Promotion was distributed to women visiting five health care facilities in Freetown, Sierra Leone. Results: Participants were more likely to have anemia in the second and third trimester than the first trimester ([chi][superscript 2] = 6.12; [chi][superscript 2] = 6.33). Participants indicating economic difficulties were likely to have anemia. Seventy-seven percent of participants had anemia (hemoglobin less than 11.0g/dL). Discussion: Findings indicate that poverty, time of intervention, and socio-cultural factors have an impact on anemia. In addition, use of radio communication is beneficial to deliver health messages to the masses. Translation to Health Education Practice: Developing and implementing comprehensive programs that consider socio-cultural factors are necessary to raise awareness and address misconceptions about anemia causes, prevention, and treatment. These programs must be multi-sectored and include participants, health care workers, government, non-governmental agencies and community. (Contains 5 figures and 3 tables.)