The study, conducted by Nasim Sadat Hosseini Divkolaye of the Iranian Blood Transfusion Organization and the Blood Transfusion Research Center in Tehran, was published as an open access review on 5 September 2026. A scoping review design was chosen deliberately because the relevant evidence is heterogeneous in study design, methodology, and outcome measures. Rather than pooling effect sizes, the approach maps the breadth of available evidence. The author searched PubMed/MEDLINE, Scopus, Web of Science, and ScienceDirect, complemented by grey literature including World Health Organization Regional Office reports, Arab Barometer surveys, and national blood service sources, with the final search completed in November 2025. Sources were screened against predefined eligibility criteria, data were charted and synthesized thematically following Joanna Briggs Institute methodology, and the review was reported in accordance with the PRISMA Extension for Scoping Reviews. Social determinants of health and capability frameworks guided the synthesis.

The technical core of the review is a comparative argument. Anemia, defined by low hemoglobin concentration, is the most common medical reason for deferring female donors, and the included evidence consistently reported higher female deferral rates attributed to this cause. But the review demonstrates that deferral statistics cannot explain the magnitude of the participation gap. The median female share of donations in the Eastern Mediterranean sits at roughly six percent, while women globally contribute close to one-third of donations. Regions where anemia is more prevalent still manage to recruit female donors at far higher rates. The arithmetic is simple: if anemia alone determined who donates, the Eastern Mediterranean should not sit at the bottom of the distribution while less iron-replete populations donate more. Something else is operating, and the review identifies it in the social and structural environment surrounding the donation decision.

That something, the review finds, begins with gendered norms and household dynamics. Women across the region reported strong altruistic intentions toward donation, yet described intersecting constraints that made acting on those intentions difficult. Unpaid care burdens consumed the time and flexibility that donation requires. Mobility limits restricted independent travel to donation sites. Restrictive social norms framed the act of giving blood as incompatible with expectations placed on women. Family gatekeeping emerged as a recurring theme, with relatives exercising effective veto power over a woman’s decision to donate. These are not marginal frictions; they are structural constraints embedded in daily life, and they operate before any donor ever reaches a clinic door or a hemoglobin test.

The second layer of the problem lies in how blood services themselves are designed. Across studies, the review reported system-level factors that effectively screen women out. Donation infrastructure in the region skews toward fixed sites with male-oriented service design, and mobile collection units are limited, which matters enormously for potential donors whose mobility is already constrained. Family replacement practices, in which patients must recruit donors from their own networks, interact with gendered household power to further reduce women’s participation. Recruitment and retention strategies were described as gender-blind, failing to account for the different circumstances of female donors. Digital divides limited access to appointment systems and information channels. Perhaps most fundamentally, the review highlighted a lack of sex-disaggregated data, which means blood services often cannot even see the scale or shape of the gender gap they are perpetuating.

The analytical lens the review proposes is drawn from capability theory and social determinants of health research. In this framing, the relevant question is not whether an individual woman has sufficient hemoglobin on a given day, but whether she possesses the real freedom to participate in donation at all. Capability depends on the interaction of biomedical factors with resources, norms, institutional design, and political economy. A woman with adequate iron stores who cannot travel to a donation center, cannot negotiate permission from family members, and faces a clinic designed around male donors is, in practical terms, excluded. The review argues that this structural lens better explains the persistence of the gap than models centered on individual biomedical deficits, and it reframes low female participation as an equity problem rather than a physiology problem.

The implications for blood system sustainability in the region are considerable. Blood supplies depend on voluntary, repeat donors, and excluding half the population from the donor pool places chronic strain on transfusion services. The review’s findings are consistent with the interpretation that closing the gap requires more than iron supplementation campaigns or donor education. The author proposes gender-responsive service design, meaning collection systems built around the realities of women’s lives, including expanded mobile units and female-appropriate facilities. Routine sex-disaggregated data collection is identified as a foundational step, since services cannot manage what they do not measure. Structural reforms that expand women’s capability to participate, addressing care burdens, mobility, and gatekeeping, are presented as necessary conditions for any durable change.

The review also carries a methodological message for the field. Because the evidence base is fragmented across study designs and outcome measures, and because sex-disaggregated donation data are scarce, the true scope of the problem is difficult to quantify precisely. The scoping review format is honest about this limitation: it maps what is known rather than estimating pooled effects. Yet the consistency of the findings across heterogeneous sources, from peer-reviewed studies to WHO reports to population surveys, strengthens the central claim. The convergence of comparative epidemiology, qualitative accounts of women’s experiences, and health system analysis points in the same direction, toward structural explanation.

What makes this study resonate beyond transfusion medicine is its broader argument about how health inequities hide behind biomedical explanations. Attributing low female donation to anemia individualizes a problem that is actually produced by institutions and norms, and it quietly absolves health systems of responsibility for redesign. The review’s comparative data dismantle the anemia narrative on its own terms, and its synthesis of social and structural determinants offers a testable alternative. If blood services in the Eastern Mediterranean adopt gender-responsive design, collect disaggregated data, and reform the practices that constrain women’s participation, the resulting changes in donation rates would provide a natural experiment on the review’s central claim. For now, the study stands as a documented case of a health system outcome shaped less by biology than by the structures surrounding it, and a warning that sustainable blood supplies in the region may depend on closing a gender gap that medicine alone cannot fix.

Subject of Research: Gendered social and structural determinants of women's blood donation in the Eastern Mediterranean Region

Article Title: Beyond anemia: gendered social and structural determinants of women’s blood donation in the Eastern Mediterranean Region: a scoping review

Article References: Divkolaye, N. S. H. (2026). Beyond anemia: gendered social and structural determinants of women’s blood donation in the Eastern Mediterranean Region: a scoping review. International Journal for Equity in Health. https://doi.org/10.1186/s12939-026-03011-w

Image Credits: AI Generated

DOI: 10.1186/s12939-026-03011-w

Keywords: blood donation, women, gender equity, Eastern Mediterranean Region, anemia, structural determinants, health systems, social norms, scoping review, donor deferral, hemoglobin, civic participation