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% maternal deaths and an indirect cause of 20-40% of maternal deaths. The current study explores socio-ecological contributing factors to the anemia status of 171 pregnant Sierra Leone women. A structural 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. Participants were more likely to have anemia in the second and third trimester than the first trimester (X2 =6.12; X2=6.33). Participants indicating economic difficulties were likely to have anemia. Seventy-seven percent of participants had anemia (hemoglobin <11.0g/dL). 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. 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.