All rights reserved. Reproduction, distribution, or translation without express written permission is strictly prohibited.
To make an informed decision on umbilical cord blood banking or donation during birth, families need evidence-based, quality information on this alternative. Cord blood banking often refers to private banking, while donation generally refers to public banking. Research has shown that expectant parents do not have sufficient understanding of the cord blood banking process, umbilical cord stem cell transplants, uses of these cells, or options. Research also shows that birthing families desire that information to come from a reliable healthcare provider resource, such as a childbirth educator. Therefore, this article will offer information for use by childbirth educators, nurses, or other birth workers to increase awareness and knowledge on the topic of umbilical cord blood banking and donation.
Keywords: cord blood banking, cord blood donation, hematopoietic stem cells, second-stage laborAccording to Peberdy et al. (2018), umbilical cord blood banking and donation should be a topic of discussion in every antenatal childbirth education class. Cord blood banking often refers to private banking, while donation generally refers to public banking. Yet this topic is often not included as either an essential or important topic to be included in childbirth classes (Peberdy et al., 2020). Quite often it is not a topic that healthcare professionals initiate, often citing their lack of knowledge on the subject (Peberdy et al., 2016; Thomas, 2017). However, this is a subject that is introduced by expectant families, as they have questions about this intervention (Peberdy et al., 2020). To make an informed, shared decision on this intervention during birth, families need evidence-based, quality education on the subject. Expectant families have been clear that their preference to receive education on cord blood banking and donation should be from healthcare professionals (Peberdy et al., 2018). Therefore, this article will provide information for the childbirth educator, nurse, or other birth worker to foster discussions on the topic of umbilical cord blood banking and donation so that expectant families can make informed decisions. Included in this article will be updates from the last 10 years when an article on this topic was last published in The Journal of Perinatal Education (Waller-Wise, 2011).
Umbilical cord blood was first described as a resource to obtain hematopoietic stem cells in the mid-1970s (Arutyunyan et al., 2018). Hematopoietic stem cells are immature cells that can differentiate into mature cells of diverse types within the body (Devi, 2016). These immature cells are most desirable because these stem cells are immunologically immature, leading to less infections, and require less stringent matching (Waller-Wise, 2011). The first umbilical cord blood stem cell transplant took place in 1988. The recipient was a 6-year-old boy, Matthew Farrow, who had Fanconi anemia, a genetic bone marrow disease. The donor stem cells came from his younger sister’s umbilical cord blood that had been frozen. While Matthew was from North Carolina in the United States, he and his family traveled to Paris, France where the transplant was performed. Prior to the stem cell transplant, Matthew’s prognosis was bleak; however, now he is currently healthy some thirty-plus years after this historic umbilical cord blood stem cell transplant (Arutyunyan et al., 2018; Kurtzberg, 2017; Waller-Wise, 2011).
Currently, hematopoietic stem cell transplants are used for four broad categories of diseases, namely, cancers, blood diseases, genetic disorders, and immunodeficiencies.
In 1990 the first unrelated donor cord blood stem cell transplant was accomplished in the United States on a 4-year-old boy with leukemia. The first public cord blood bank followed in the early 1990s (Kurtzberg, 2017). At this point cord blood stem cells have been preserved for over 25 years (Huang et al., 2019; Roura et al., 2015). Worldwide, it is thought that there are approximately 800,000 units of umbilical cord blood currently stored in public banks while as many as 4 million units are stored in private cord blood banks (Guerra-Marquez et al., 2020).
Collection of umbilical cord blood can be accomplished with either a vaginal or surgical birth, and with spontaneous labor or induced labor (Roura et al., 2015). Often between 60 to 300 milliliters (mL) of cord blood can be collected (Devi, 2016). According to the American College of Obstetrics and Gynecologists (ACOG) at least 40 mL must be collected to ensure an adequate cell size (ACOG, 2019). Prior to collection the birthing person is screened for any communicable diseases (Adams et al., 2018). Retrieval of the cord blood can take place prior to the release of the placenta, or after its expulsion (Devi, 2016). Collection of the cord blood can be completed quickly, usually in under five minutes. Cord blood is placed in a medium of an anticoagulant and transported to a laboratory for processing in a regulated environment (Roura et al., 2015).
Once at the storage laboratory, the sample is tested for infectious diseases (Matsumoto et al., 2015). Often tests for total nucleated cell (TNC) count, viable CD 34 content, and the presence of granulocyte-macrophage progenitor cells are performed. These are often considered the minimum requirements for pureness and effectiveness of the stem cell sample (Rich, 2015). Outcome measures associate a higher cell count with better after-effects of stem cell transplantation (Sacchi, 2018). The sample is then labeled for identification and frozen, a process called cryopreservation (Devi, 2016). If the sample is deemed to be less than an adequate sample, it may be discarded (Roura et al., 2016).
For the stem cells to be transplanted, the donor cells and the recipient must be matched for human leukocyte antigen (HLA) differences (Armitage, 2016; Dessels et al.,2018). An advantage of using umbilical stem cells is that more of a mismatch can be tolerated with these immature stem cells than with use of bone marrow stem cells, for example (Armitage, 2016). Additionally, there is much less risk of rejection of the stem cell transplant when the source of the hematopoietic stem cells is from umbilical cord blood (Dessels et al., 2018). Typical HLA matching for transplants is for six total antigens (Waller-Wise, 2011). However, with umbilical cord blood samples the aim is for a four out of six match, and in some cases a match of three out of six is permitted (Guerra-Marquez et al., 2020). See Table 1 for advantages of umbilical cord stem cell transplants.
| Easy to collect |
| Risk-free to mother and newborn |
| Processing time less than for bone marrow stem cells |
| Costs less than bone marrow stem cells |
| Decreased risk of transmitting infection |
| Decreased need for exact HLA-matching |
| Decreased rejection |
One disadvantage of using umbilical cord blood hematopoietic stem cells is that it takes longer for these cells to produce the therapeutic effect needed. Thus, prolonging improvement and potentially increasing costs associated with extended hospitalization for illness. Another constraint is the limited TNC counts within a single unit of umbilical cord blood. To overcome this deficit often two units of cord blood is used for a treatment dose (Dessels et al., 2018). See Table 2 for disadvantages of umbilical cord stem cell transplants.
| Increased time for engraftment |
| Limited total cell count |
| Small volume |
| May require additional units administered |
| Autologous transplants limited benefit with some inherited disorders |
| Storage Inconsistencies between public and private banks |
Efforts are underway to improve the efficiency of the umbilical cord blood stem cells. One of these ways is through improvements in the collection of cord blood. Studies have shown that collection of cord blood in a way in which the blood never encounters oxygen in ambient room air improves the resulting collected cells. Likewise, attempts are being made to improve the homing capability of the stem cells obtained from cord blood (Huang et al., 2019). Homing refers to the ability of the cells to target or “home in on” the exact locations where the damaged tissue or cells exist in the recipient (Liesveld et al., 2020).
Currently, hematopoietic stem cell transplants are used for four broad categories of diseases, namely, cancers, blood diseases, genetic disorders, and immunodeficiencies (Roura et al., 2015; Waller-Wise, 2011). The highest percentage of umbilical cord stem cell transplants in both adults and children tends to be for some form of leukemia (Guerra-Marquez et al., 2020; Roura et al., 2015). For sickle cell anemia, a genetic blood disorder, hematopoietic stem cells transplants are the only known therapy to cure this disease, having a greater than 90% success rate (Rafii et al., 2017). Umbilical cord blood transplants are now considered an accepted treatment for over 80 different disorders (Peberdy et al., 2016). See Table 3 for examples of disorders treated with umbilical cord stem cell transplants.
| Cancers | Blood Disorders | Metabolic Disorders | Immunodeficiencies |
|---|---|---|---|
| Leukemias | Sickle-cell anemia | Adrenoleukodystrophy | Wiskott-Aldrich’s syndrome |
| Lymphoma | Fanconi anemia | Tay-Sachs’ disease | Duncan’s disease |
| Neuroblastoma | Aplastic anemia | Globoid leukodystrophy | Hypogammaglobulinemia |
| Myeloma | Congenital cytopenia | Hunter Syndrome | Adenosine deaminase deficiency |
Research on hematopoietic stem cell transplants has broadened for use in neurological and regenerative medicine applications (Dessels et al., 2018). Experimental therapies include cerebral palsy, types 1 and 2 diabetes, autism, Alzheimer’s disease, neonatal hypoxic-ischemic encephalopathy, spinal cord injury, and others (Dessels et al., 2018; Roura et al., 2015). Of importance, many of the neurological and all the regenerative uses of umbilical stem cells remain in clinical research only. However, short term reports of these research studies show favorable results. As the clinical research concludes, medicine will gain a deeper understanding for these potential uses of umbilical cord blood stem cells (Dessels et al., 2018).
There are three types of umbilical cord blood banks. These are public banks, private banks, and hybrid banks (Dessels et al., 2018; Matsumoto et al., 2015). Public cord blood banks, like venous banks, are based on altruistic motives. They tend to be not-for-profit entities (Roura et al., 2015). Public banks collect cord blood and keep it for an indefinite period for whenever and whoever needs it for a medical use. Donations are made to public banks without financial obligation (Armitage, 2016). This process is different from bone marrow stem cell processes, where bone marrow stem cells are only gathered when a need and donor are preidentified (Strong et al., 2018). The units available in a public bank are cataloged and registries can be searched both nationally and internationally. Processing fees are charged to cover some of the costs of storage and administration. Public banks receive other funding from philanthropic donations, government funding, and grants (Armitage, 2016).
Private banks are often called family banks. With these banks the donors pay the bank for storage of the cord blood, which is held until the donors release the cells for use. Typically, these cells units are used by the donor family or a matched relative (Dessels et al., 2018). Private banks charge an upfront fee for initial collection, then an annual charge to manage the cells units. Therefore, these are for-profit banks. Private banks are typically less regulated than public banks; therefore, quality may suffer (Armitage, 2016).
In this latest statement the AAP reaffirms its endorsement of storage of cord blood in public banks, as the evidence shows positive outcomes for hematologic cancers, abnormal hemoglobin disorders, immunologic disorders, and inherited metabolic disorders.
Hybrid banks are a combination of public and private banks. Often, these are listed as either a public or private bank but offer the services of the other alternative. For example, a public bank that offers a private option for a designated fee (Dessels et al., 2018). Another type of hybrid bank allows for the donation of cord blood for a designated pre-matched relative of the donor. These programs are often called a directed donor bank (Armitage, 2016).
In 2005, in the United States (U.S.) the Stem Cell Therapeutic and Research Act was authorized to, among other things, establish the formation of a National Cord Blood Registry and authorized the National Marrow Donor Program to oversee it. This law also established an Advisory Council for Blood Stem Cell Transplantation and funded public cord blood banks within the U.S. (Rich, 2015). The aim of this regulation was in part to maintain high-quality umbilical cord blood units, so that they would be available for transplantation. Specifically, the law provided for the original gathering and preservation of 150,000 units, so that these units would be available as needed. Funds were also designated to increase the genetic diversity of the stem cells, so that a wide variety of individuals of various genetic backgrounds would benefit. This act was reauthorized in 2010 and 2015 (Strong et al., 2018).
In 2009, the U.S. Federal Drug Administration (FDA) designated the use of umbilical cord blood cells as a drug, due to the systemic nature of their effect. This regulation mandated that cord blood banks apply for a Biologics License. These guidelines were updated in 2014 (Rich, 2015). United States cord blood banks, both private and public, are episodically inspected for adherence to these standards (Armitage, 2016).
There are similar regulations designated by the European Union (E. U.) with respect to cord blood donation, collection, screening, testing, processing, cryopreservation, and administration of units for transplantation. In 2004, these guidelines detailed private banks were not supported, while altruistic donation, matched transplantation, and clinical research were to be the norm. The E. U. required that educational information be truthful, and that informed consent be obtained prior to the procedure of cord blood collection. Finally, the E. U. set out that cord blood banks should adhere to specific quality standards (Armitage, 2016).
Cord blood from private banks are underutilized, have less quality control, and are more costly for individual families.
In Canada, the regulation of cord blood banks falls under the purview of Health Canada, under the Safety of Human Cells, Tissues and Organs Transplantation Regulation of 2007. Likewise, in Australia, the Therapeutic Goods Act of 1989 oversees the licensure of cord blood banks. This law requires a “risk management” methodology to assure the “quality, safety, and efficacy” of hematopoietic cord blood stem cells for transplantation (Armitage, 2016, p. 3).
In 2019, the board of directors of the Cord Blood Association, a multinational organization, adopted the first ever “Model Criteria for Regulation of Cord Blood Banks and Cord Blood Banking.” These guidelines outline specific criteria for quality management, informed consent from donors, prescreening and testing, collection, processing, potency, shipping and transportation, outcome measures of quality, and data sharing (Cord Blood Association, 2019). Many believe that these guidelines were past due but are an excellent first step for ensuring international quality and consistency (Broxmeyer, 2019).
The American Academy of Pediatrics (AAP) updated their policy on cord blood banking in 2017. In this latest statement the AAP reaffirms its endorsement of storage of cord blood in public banks, as the evidence shows positive outcomes for hematologic cancers, abnormal hemoglobin disorders, immunologic disorders, and inherited metabolic disorders. The AAP makes the case that cord blood from private banks are underutilized, have less quality control, and are more costly for individual families. The only time that the AAP would recommend private cord blood banking is when there is a disease or disorder in a family member that is usually treated with hematopoietic stem cells which is known prior to the birth of a child (Shearer et al., 2017).
In 2019, the American College of Obstetricians and Gynecologists (ACOG) revised its previous policy statement on cord blood banking. ACOG upheld the view of the AAP to endorse the storage of hematopoietic stem cells in public rather than private cord blood banks. ACOG endorses the dissemination of knowledge about cord blood banking in a fair, ethical, and comprehensive manner. They continue to state that families of all ethnicities should consider donation to a public bank to enlarge the accessibility of stem cells for all possible matches. ACOG further states that in an emergency, care of either mother or newborn should not be delayed collecting cord blood (ACOG, 2019).
Lamaze International (2019) does not have a policy statement directly related to umbilical cord blood banking. There is a statement related to advertising, which maintains that there is to be no advertising of private cord blood banks on any Lamaze mass media instrument. This is in essence disapproval of private cord blood banks. In their book, Giving Birth with Confidence: The Official Lamaze Guide, Lothian and DeVries discuss cord blood banking; however, the context is generally limited to private banking with little mention of public banking (Lothian & DeVries, 2017). It is of interest that in the World Health Organization’s (WHO) WHO recommendations: Intrapartum Care for a Positive Childbirth Experience, umbilical cord blood collection and banking are not mentioned at all (WHO, 2018).
Discussions of umbilical cord blood banking brings up ethical issues that should be addressed. The first is the marketing practices of private cord blood banks or the issue of “truth in advertising.” Many times, the medical advertised reasons for why a family should bank the umbilical cord blood are distorted. The advertisements are laced with promises of cures for diseases for which current therapies do not exist. In fact, as previously reported the diseases may be in clinical trials but not actual treatment phase of care. The private banks can utilize this tactic because “the actual product or service offered is the banking of blood, not the predicted or hypothesized future treatments that may be mentioned in marketing” (Murdoch et al., 2020, p. 3).
Similarly, the private banks do not advertise that there is a very low probability of a family using the cord blood that they have stored (Murdoch et al., 2020). In fact, one study of private cord blood banking for treatment of sickle cell disease, a known use of hematopoietic stem cells, over a 20-year period found only an 8% utilization rate (Rafii et al., 2017). Studies show that less than 50% of parents can correctly identify uses of stored umbilical cord blood (Peberdy et al., 2018). Likewise, parents are not always aware that saved cord blood cells cannot be used to treat leukemia in the same child from where the cord blood came, as those stem cells already have a marker for precancerous cells (Shearer et al., 2017). Families are often not able to make truly informed decisions as they are in an emotionally charged time and see the promises of the private cord blood banks as “biologic insurance” (Matsumoto et al., 2015). Overall, this can lead to alterations in public health and financial harm to individual families (Murdoch et al., 2020).
Discussions of umbilical cord blood banking brings up ethical issues that should be addressed.
Another ethical issue involves kickbacks to or ownership of private cord blood banks by physicians. When there is a vested interest in the profits of the bank, it leads to ethical dilemmas with physicians marketing and/or obtaining informed consent for collection (Murdoch et al., 2020). Similarly, healthcare professionals often report that their prime source of information on cord blood banking comes from the literature of private cord blood banks themselves (Peberdy et al., 2016).
A final ethical consideration is that of timing of umbilical cord clamping. In a study by Peberdy et al. (2020) findings showed that healthcare providers did not use evidence-based guidelines for when to clamp the umbilical cord. While they reportedly used delayed cord clamping, each clinician defined delayed cord clamping differently. In addition, timing of cord clamping varied if there was collection of cord blood for banking (Peberdy et al., 2020). The guidelines are also varied among organizations. WHO states that cord clamping should be delayed at least one minute (WHO, 2018). ACOG varies from that with their guidelines by stating at least 30–60 seconds of delay after birth before clamping the umbilical cord (ACOG, 2020). ACOG describes a lower total cell count when cord clamping is delayed (ACOG, 2020); however, international cord blood banks report that delayed clamping does not decrease the competence of the unit of cord blood when performed by a skilled obstetrician (Sacchi, 2018).
Research has shown that expectant parents do not have adequate knowledge of cord blood banking process and options but that they desire to have that information from a reliable healthcare provider resource. Generally, expectant parents prefer cord blood donation to a public cord blood bank as an altruistic contribution to society fostering public health (Peberdy et al., 2018). Matsumoto et al. (2015) declared that the key to public cord blood banking’s success would be an increase in societal familiarity of the process. Peberdy and colleagues (2018) have specified that they believe that the topic of umbilical cord blood banking should be added to the program of study of childbirth education classes (Peberdy et al., 2018). Childbirth educators should consider adding this topic to their classes and should at the least be knowledgeable to lead a discussion on this topic should expectant parents raise questions about this during classes.
Overall, there has been a decrease in public cord blood donation over the last several years (Dessels et al., 2018). This is in part due to improvements in haploidentical transplants, where stem cells from a partially or “half-matched” donor cells are used (Dessels et al., 2018; Guerra-Marquez et al., 2020). Another issue to consider is minority diversity of umbilical cord blood donation. Currently, approximately 80% of non-Caucasian patients requiring a stem cell transplant cannot find suitable matching from the international inventory (Dessels et al., 2018). Further research should be conducted on the awareness, knowledge, and attitudes of birthing families on the topic of umbilical cord blood banking and donation (Peberdy et al., 2018). Similarly, there should be an exploration of the decision-making for or against cord blood banking and donation (Valle et al., 2017). Much can be learned from these families that will benefit birthing professionals and broaden knowledge. Perhaps, increasing knowledge of donation can increase the ethnic diversity of banked stem cells.
Medical knowledge should be expanded to continue to improve the usefulness of cord blood stem cells by both improving the stem cells themselves and exploring the use of these enhanced cells in clinical research (Huang et al., 2019). Currently conducted and recently concluded research on the established, regenerative, and new uses of hematopoietic umbilical cord stem cells will add to the knowledge base when the results are analyzed and reported (Dessels et al., 2018; Roura et al., 2015). Positive outcomes have been reported on uses with neurologic and regenerative disorders; however, more research is needed to establish recommendations (Dessels et al., 2018).
Finally, new uses for umbilical cord blood and cord tissues are beginning to be explored. Umbilical vessels cryopreserved in saline show promise as a source for vascular transplants. Wharton’s jelly from umbilical cords is being used to aid in wound healing (Arutunyan et al., 2018). Mesenchymal stem cells, which produce fat or bone, are also present in umbilical cord blood. Methods to isolate these are being explored (Roura et al., 2016). Continued research into uses of these once discarded substances will bring insight and improvement in healthcare.
RENECE WALLER-WISE is licensed in Alabama as a women’s health clinical nurse specialist. She is the program director and principal educator for Teach You! Childbirth in Spring, TX, and she is a lecturer for Sam Houston State University School of Nursing. She has been teaching childbirth education classes for almost 40 years, and has been a Lamaze Certified Childbirth Educator for 20 years.
The authors have no relevant financial interest or affiliations with any commercial interests related to the subjects discussed within this article.
The author(s) received no specific grant or financial support for the research, authorship, and/or publication of this article.