Bloodtobaby is committed to educating about the critical question’s women, midwives and other maternity workers may have about umbilical cord blood banking in order to ensure physiology is not compromised whilst also considering aspects like parent education and informed consent. Please see our website for more details.
So, we are delighted to publish this blog by second year Student Midwife Coral Mewett who reflects on practice and challenges the very sensitive issues around cord blood donation and banking.
This also blog summarises issues presented in our new cord blood banking module - due for release in September.
Background
Stem cell therapy and donating cord blood to aid research is not a new phenomenon, it has been happening for years. However, it is in recent years that blood banks have been able to join hospital trusts and work exclusively within the hospital. On the whole this can improve the rates of donation and public knowledge of stem cell therapy and its importance.
It cannot be denied that advances in medicine due to stem cell research and therapy have been profound, and the media has extensively covered this. The NHS opened its own cord blood bank in 1996 and since then a vast amount of public and private banks have become available to women (NHS Blood and Transplant, 2019).
Practice experiences
My knowledge of public cord blood banking has been established through clinical placement in the community and on labour ward. Women are introduced to the option of donating cord blood at the booking appointment when a leaflet is given to them in the pack of information supplied.
The leaflet details why cord blood is so important to research, how it can be donated, and suggests that it doesn’t impact on the woman’s birth plan or carry any risks.
Women can then fill in the leaflet, further paperwork is sent to them to read and sign and finally a sticker placed on the maternity notes indicating that this woman would like to donate once she has given birth.
Problems and informed consent
Women can research cord blood donation online or through resources given to them by their community midwife. However, the literature appears to miss out on some of the crucial elements of cord donation. To truly gain informed consent, I believe women should be educated on the benefits afforded to their baby when delayed or optimal cord clamping is practiced.
The literature and online sources inaccurately state that if not donated, blood is thrown away. This is grossly misleading and simply untrue. It is the babies first right to have its own stem cell transfer at birth, NICE recommend a minimum of waiting 1 minute until clamping the umbilical cord (NICE, 2014). However, 1 minute is considered arbitrary (Tizard and Burleigh, 2018) and research shows that up to 5 minutes has long term benefits (Mercer et al., 2018).
In practice, it is not uncommon for woman to consent to cord blood donation whilst in the first stage of labour. Although many women are of sound mind and are able to communicate clearly at this stage, is it ethical and woman centred to disturb the birth room environment to carry out the task of consenting to cord blood donation?
When the cord is left unclamped, we know the baby receives its own stem cell transfer. When immediate cord clamping is carried out, the baby is denied its own volume of blood. By denying this stem cell transfer we are interfering with the natural physiology of the neonate as it adapts to extrauterine life.
We need to ask ourselves if women were truly educated on the benefits of optimal cord clamping, would they choose to not do it? The priority should be allowing normal physiological processes to occur.
Organisational position
RCOG and RCM have stated their support for public cord banks to seek voluntary donations in maternity settings. Although, they also state that this should in no way alter the management of the third stage of labour:
“It is vital that the obstetrician or midwife are not distracted from the immediate care of the mother and baby during the third stage of labour; and the management of the third stage is not altered or compromised. There is so also the issue of the timing of the clamping of the cord as this will have an effect on the collection of cord blood. Evidence suggests that immediate cord clamping in preterm babies may be harmful to them. In a healthy newborn, deferring clamping may enhance placental transfusion and reduce jaundice and low iron stores at birth (RCOG, 2009). Both the RCOG and RCM strongly believe that interference with the third stage of labour needs to be kept at a minimum to ensure good outcome for both mother and baby (RCM and RCOG, 2011).”
We believe the literature and education given to women should be reviewed and changed to allow for true informed choice to be made. When all the benefits of both have been presented and the women has made a choice there will still be a positive outcome.
Rewards
Furthermore, should questions be asked about the “goody bags” that are gifted to parents that donate cord blood and somewhat glorify the donation process. Baby grows, car signs and certificates acknowledging the infant as a life saver are typically given.
This is viewed as unethical, given that gifts are frowned upon in the healthcare system. The sentimental value is lovely for a parent who believes they have just possibly gifted cord blood which could potentially be used to save someone’s life, but have they gifted something whilst unknowingly denying their baby it owns stem cells?
Choice and control
There is also the issue that within hospitals that offer public cord donation, women cannot choose to bank their infants’ own blood with a private company.
Whilst therapies offered by private cord blood banks are considered experimental, research has shown safe and feasible treatments for conditions like autism (Dawson et al., 2017) with many more trials ongoing (Dessels, Alessandrini and Pepper, 2018).
Given that the benefits of stem cell research and therapy are what public banks centre their advertising around, it is incomprehensible that the health care system can deny a woman the chance store her own infants cord blood for future use if that is what the family so wish to do. Some private cord blood banks have the ability to only require very small samples which are shown to be therapeutically useful (Cells4Life, 2019). This of course with the proviso that the same truly informed consent is gained and that the parents understand its cost, value and probability of use.
This raises human rights issues. The placenta, cord and cord blood are a product resulting from pregnancy. Women have ownership of their placenta and decide what happens with it once they have birthed. Surely this is no different to a woman deciding she wants to take her placenta home with her to facilitate placenta encapsulation or homeopathic treatments, which are enabled without question.
Summary
There is no denying that the advances in medicine through stem cell research and therapy have been profound, stem cell transplantation is a potentially life‐saving treatment option for children and adults with blood cancers with likely further regenerative treatments available in the future and this area of medicine needs donations to continue.
Nonetheless, women are deserving of the right to donate or privately bank cord blood with the full information, benefits and risks AND most importantly understanding the significance of delayed and optimal cord clamping for their babies long short- and long-term health and development.
You can follow Coral @coral_stmw on Insta and @coralSTMW on Twitter
References
Cells4Life, (2019). Cells4Life (2019). Delayed cord clamping with cord blood banking | Cells4Life. [online] Cells4Life. Available at: https://cells4life.com/cord-blood-banking-overview/delayed-cord-clamping/
Dawson, G., Sun, J., Davlantis, K., Murias, M., Franz, L., Troy, J., Simmons, R., Sabatos-DeVito, M., Durham, R. and Kurtzberg, J. (2017). Autologous Cord Blood Infusions Are Safe and Feasible in Young Children with Autism Spectrum Disorder: Results of a Single-Center Phase I Open-Label Trial. STEM CELLS Translational Medicine, [online] 6(5), pp.1332-1339. Available at: https://stemcellsjournals.onlinelibrary.wiley.com/doi/full/10.1002/sctm.16-0474
Dessels, C., Alessandrini, M. and Pepper, M. (2018). Factors Influencing the Umbilical Cord Blood Stem Cell Industry: An Evolving Treatment Landscape. STEM CELLS Translational Medicine, 7(9), pp.643-650.
NHS Blood and Transplant (2019) Cord blood donation (online) Available from https://www.nhsbt.nhs.uk/cord-blood-bank/
NICE (2014) Intrapartum care for healthy women and babies (online)Available from https://www.nice.org.uk/guidance/cg190/chapter/Recommendations#third-stage-of-labour
Mercer, J., Erickson-Owens, D., Deoni, S., Dean, D., Collins, J., Parker, A., Wang, M., Joelson, S., Mercer, E. and Padbury, J. (2018). Effects of Delayed Cord Clamping on 4-Month Ferritin Levels, Brain Myelin Content, and Neurodevelopment: A Randomized Controlled Trial. The Journal of Pediatrics, [online] 203, pp.266-272.e2. Available at: https://www.jpeds.com/article/S0022-3476(18)30775-3/fulltext
RCM and RCOG (2011) RCOG/RCM statement on umbilical cord blood collection and banking. [eBook] London: RCOG, p.1.
RCOG (2009) Scientific Advisory Committee Opinion Paper 14; clamping of the umbilical cord and placental transfusion. London: RCOG
Tizard, H. and Burleigh, A. (2018). Nature’s first stem cell transfer occurs at birth. [online] All4Maternity.com. Available at: https://www.all4maternity.com/natures-first-stem-cell-transfer-occurs-at-birth/