Introduction Anemia prevalence in pregnancy ranges from 51%-60% globally. Genetic disorders, infectious diseases, reproductive factors, nutritional deficiencies, and poverty can affect anemia status. Anemia can negatively impact economic progress, social and intellectual development, and maternal health. Estimates indicate that anemia is the direct cause of 3-7% of maternal deaths and an indirect cause of 20-40% of maternal deaths. Although several initiatives by the international community address the anemia problem, prevalence remains unacceptably high in Sierra Leone at 2,000 per 100,000 live births. This study explored ecological determinants of anemia status of pregnant women living in Freetown, Sierra Leone. Method This was a mixed-method, retrospective, unmatched case-control research study based on the Modified Ecological Model for Health Behavior and Health Promotion. One hundred and seventy one pregnant women, who visited one of five health facilities were interviewed for the study. Anemic participants' (Hgb<11.0g/dL) responses were compared to responses of non-anemic participants and the differences were assessed. Content analysis and descriptive statistics were used to assess qualitative knowledge items, whereas t-tests were conducted to determine if mean knowledge differences existed between those with anemia and those without. Chi-square was used to analyze forced choice attitude items: perceived threat to anemia and perceived benefits of anemia prevention and treatment. Chi-square was also used to analyze selected behaviors and perceived barriers to anemia prevention and treatment. Odds ratio determined the strength of the relationship between the dependent variable (anemia status) and selected exposure variables (modifying factors). Results Seventy-seven percent of participants were anemic (M: Hgb=9.63g/dL). Those with anemia were more likely to first see a health care provider after 12 weeks of pregnancy (p<.05). Participants who earned income in the top two quintiles were less likely to have anemia than those in the lower three quintiles (p=.007). Participants who had anemia were more likely to cite lack of finances as a barrier to seeking prenatal services (p=.007). Although differences existed between participants who had anemia and those who did not have anemia, they were generally not statistically significant for knowledge, behavior or modifying factors. Participants who had pica, however, were more likely to have anemia than those who did not (p=.005). There was misinformation among participants about the use of palm oil, Vimto and "blood tonic" as treatment options. In addition, participants cited family and friends as sources of this same information as well as correct suggestions and information about anemia prevention and treatment. Discussion Health providers need to be clearer about messages that they deliver to service users to reduce misinformation about anemia prevention and treatment. Community awareness about anemia, anemia causes, anemia prevention and anemia treatment needs to be raised. Information, particularly about anemia causes, need to be disseminated and programs to address those causes need to be developed and implemented. Program development and implementation should be a comprehensive effort that includes training traditional birth attendants and lay health workers. Efforts should incorporate health efforts from government agencies, the non-governmental sector, donor groups, and community and civil society groups to deliver culturally and regionally appropriate interventions.