n the August 2008 issue of American Baby magazine, several adver- tisements appear regarding cord blood banking. Viacord’s advertisement promotes banking as a once in a lifetime opportunity for parents. The ad presents a family’s story about cord blood banking, depicting how a cord blood transfusion reduced the number of insulin shots their 11-year-old received from 42 injections per week to 7 per week (Viacord, 2008). This story illustrates a case of cord blood being used to treat type 1 diabetes; however, the ad’s disclaimer notes that this type of treatment is currently in the experimental stage. Trying to appeal to more parents, the ad suggests that in the future cord blood will be able to treat more diseases than pres-ently proven.

Umbilical Cord Blood

Banking

Beth Percer, RN, MSN

Helping Parents Make Informed Choices

I

A second ad in the same magazine even provides a coupon of-

fering $155 off private cord blood banking. This ad, sponsored

by the Cord Blood Registry, states that 70 diseases have been

treated with cord blood stem cells, and that if parents don’t

bank their newborn’s cord blood, they’ll “be passing up the best

medical option for tomorrow.” The ad employs the well-known

Dr. Sears to promote this specific cord blood registry, giving

his commentary about banking his own son’s cord blood, plus

mentioning that payment plans are available to make the cost

within reach for families (Cord Blood Registry, 2008).

A question being asked by many is whether it’s ethical for

popular parenting magazines to print ads encouraging private

cord blood banking when there are still many uncertainties re-

garding success and treatment.

A Hot Topic Cord blood banking is a hot topic among pediatricians, obste-

tricians, family physicians, nurse practitioners, midwives and

others caring for pregnant women and newborns. A survey in

2003 by Fernandez, Gordon, Van den Hof, Taweel and Baylis

(2003) revealed that 68 percent of women questioned desired

receiving information about umbilical cord blood banking

from their prenatal care provider. In addition, 70 percent of

these women stated that they had poor to very poor knowledge

regarding this possible option.

New parents have a multitude of decisions to make during

pregnancy, such as choosing a pediatrician or nurse practitioner,

selecting their baby’s name and deciding on childcare options,

just to name a few. Presently, in magazines, in OB/GYN offices

and in discussions with others, parents are confronted with cord

blood banking as another decision. Health care providers need

to be aware of the latest information about cord blood banking

in order to provide evidence-based care to patients when ques-

tioned. This article discusses background information on cord

blood banking as well as the benefits and potential drawbacks.

In addition, a discussion of different respected organizations’

views on cord blood banking will be included.

Background InformationThe four main sources of stem cells are embryonic blood, pe-

ripheral blood, bone marrow and cord blood (Box 1). The ben-

efit of stem cells is their ability to differentiate into any type of

cell or tissue, making them pluripotent cells. Before cord blood

transplantion became widespread, bone marrow transplants

benefited thousands of individuals; the first successful umbili-

cal cord blood transplantation occurred in 1989 (Gluckman et

al., 1989). Since then, thousands more cord blood transplants

have benefited numerous children. The first cord blood-bank-

ing center formed in New York in 1991 after the potential ben-

efits and opportunity of cord blood usage was realized. Now,

hundreds of cord blood banking centers exist worldwide. Many

private blood banks have been created to cash in on the poten-

tially profitable endeavor. In addition, the National Heart, Lung,

and Blood Institute, National Marrow Donor Program, Ameri-

can Red Cross and certain academic programs fund public cord

blood banks. All of these banks are in business to provide cord

blood stem cell treatment for conditions such as leukemia, lym-

phoma, myelodysplasia, aplastic anemia, hemoglobinopathies,

metabolic storage diseases and immunodeficiencies (Brunstein,

Setubal, & Wagner, 2007; Jacobsohn et al., 2004; Jaing et al.,

2005; Kobayashi et al., 2006; Krivit, 2004) (Box 2).

Potential BenefitsOnce considered a waste product of placental delivery, cord

blood is now considered a valuable material. Cord blood can

be used to treat many disorders that bone marrow stem cells

are used to treat, and has some definite advantages over bone

marrow, including ease of collection (Rocha & Locatelli, 2008).

After infant delivery, the umbilical cord blood is collected by

hospital staff, then sent for processing and cryopreservation at

the selected cord blood bank (Moise, 2006). The banked blood

becomes readily available within days after the processing, of-

fering a time-saving factor compared with bone marrow search

and collection processes that can take weeks.

Additionally, no pain or risk is inflicted upon the infant

or mother during the collection process. A diminished risk

218 © 2009, AWHONN http://nwh.awhonn.org

Beth Percer, RN, MSN, is a graduate of the University of Tennessee, Knoxville Women’s Health Nurse Practitioner Program. Address cor-respondence to: bporter100@hotmail.com.

DOI: 10.1111/j.1751-486X.2009.01422.x

• Stem cells from umbilical cord blood have been used to treat certain diseases.

• Cord blood banking can be done via private or public banks, and parents need to understand the differences.

• Parents may be susceptible to exaggerated marketing claims and, therefore, need thorough, unbiased education from qualified health care providers.

Bottom Line

Box 1

Main Sources of Stem Cells

Embryonic blood

Peripheral blood

Bone marrow

Cord blood

June July 2009 Nursing for Women’s Health 219

of acute graft-versus-host reaction provides another benefit

(Rocha et al., 2001). This is because the cord-blood-derived

lymphocytes, a type of white blood cells, are immunologically

naïve, and the T-cells produce fewer cytokines and natural killer

cells (Garderet et al., 1998). Thus, there is less potential for an

immune response. Because cord blood requires less stringent

matching of human leukocyte antigens (HLA), which are the

antigens on the outside of cells that help an immune system to

distinguish self from nonself, greater numbers of recipients can

benefit from a smaller donor pool.

Fewer cells are needed for cord blood transplantation, as

cord blood has a higher proliferative potential than bone mar-

row, with 50 to 100 mL of umbilical cord blood being adequate

to transfuse a child or small adult. Cord blood may become

readily available for adult use in the future, due to research

taking place concerning stem cell harvesting, the possibility of

multiplying stem cells once collected to increase the number

of cells, and more efficient means of storage (Schoemans et al.,

2006). Because treatment options may be expanded for cord

blood banking, it offers many positive aspects.

Concerns Cord blood transplantation success depends on cell dose per

weight of the recipient. In the past, only children have benefited

from transplantation. As mentioned above, research is under

way to multiply stem cells before transplantation, or to use com-

bined cord blood units for transplantation so that adolescents

and adults can receive treatment (Moise, 2006). However, this

research is still in its infancy. Unlike a bone marrow recipient, a

cord blood recipient cannot go back to the same infant donor

to receive further cord blood stem cells, thus limiting the size of

individuals who can currently receive stem cells successfully.

The long-term storage success of cord blood banking is still

unknown, as cord blood banking is a relatively new process.

A study by Kobylka, Ivanyl, and Bruer-Vriesendrop (1998) re-

vealed that cord blood can successfully be stored for at least 15

years after initial freezing. Further research, however, is needed

to expand and confirm this finding. Only time will tell about

long-term storage potential and success.

Current estimates range from 1 in 400 to 1 in 200,000 as

the odds that children will need to and be able to use their own

stem cells, known as an autologous transplantation (Kline,

2001; Pasquini, Logan, Verter, Horowitz, & Nietfeld, 2005). This

is because the likelihood of individuals using their own banked

cord blood is low due to their stem cells already having the

In magazines, in OB/GYN off ıces and in discussions with others, parents are confronted with cord blood banking as another decision

Box 2

Conditions Treated With Cord Blood Therapies

• Leukemia

• Lymphoma

• Myelodysplasia

• Aplastic anemia

• Hemoglobinopathies

• Metabolic storage diseases

• Immunodeficiencies

220 Nursing for Women’s Health Volume 13 Issue 3

genetic defect or predisposition to the disease needing treat-

ment. For instance, children cannot use their own stem cells

to treat malignant cancers or leukemia, as DNA mutations al-

ready exist in their cord blood (Johnson, 1997). Thus, research

has revealed that cord blood may not benefit children as an au-

tologous transplantation, but the benefit of an allogenic trans-

plantation, in which cord blood is donated from a sibling or

unrelated donor, can still be successful and considered a viable

option. Other benefits and drawbacks exist depending upon

whether private or public banking options are chosen.

Private vs. Public BankingThe two types of cord blood banking options available to par-

ents are private (for-profit) or public (not-for-profit) cord

blood banks. Each option provides positive and negative as-

pects for families plus health care providers to consider when

deciding if either option is desirable for their specific situation.

The issue of cost is a major deciding factor in many parental de-

cisions, with upfront fees for private cord blood banking rang-

ing between $995 and $1,999, plus annual storage fees ranging

between $99 and $150. If the blood is needed at a later time for

transplantation, insurance is billed the shipping and processing

fees. However, most of the fees are assumed by the family (Par-

ents Guide to Cord Blood Foundation, 2008a). Thus, private

banking is a costly decision that not all families can afford.

The second option, public cord blood banking, exists free of

charge to those willing to donate. Insurance companies reim-

burse the public cord blood banks for the blood only when the

blood is used for transplantation. Therefore, parents incur no

charges to donate to public banks, unless the OB/GYN charges

a small fee.

Although parents avoid the cost issue with public cord

blood banking, they need to be aware of other issues before

donating. With public cord blood donation, families will not

have access to their baby’s stem cells in the future as they would

have with private banking. Also, with public donation, detailed

informed consent is required together with an extensive medi-

cal and family history that is taken before blood collection. If

any abnormalities are found genetically, hematologically or im-

munologically, the parents are notified, and the blood will be

deemed unusable for transplantation. Parents must additional-

ly be informed that if too small an amount of blood is collected,

then it will be used instead for research purposes. It’s estimated

that as much as 71 percent of public cord blood donations is

rejected due to the rigorous testing that occurs on the blood,

including genetic and infectious screening, as well as quality

testing (McCullough & Clay, 2000). Still, public banking can

offer many benefits to those in need of cord blood.

Views of Organizations and GroupsPrivate cord blood banks strongly promote that all parents

should bank their infants’ cord blood for “biological insurance”

against future diseases. Respected organizations, however, such

as the American Academy of Pediatrics (AAP), American Col-

lege of Obstetricians and Gynecologists (ACOG), World Mar-

row Donor Association (WMDA) and American Society of

Blood and Marrow Transplantation (ASBMT) do not recom-

mend private cord blood banking for every family.

The AAP currently recommends that cord blood collection

be discouraged for personal or family use. The academy’s rea-

soning is that cord blood already contains the DNA with the

disease that the family may want to treat, making stem cells

of no use to them. So, private storage as “biological insurance”

for parents is discouraged. The AAP (2007) states that “private

cord blood banks target parents at an emotionally vulnerable

time when the reality is most conditions that might be helped

by cord blood stem cells already exist in the infant’s cord blood”

(Kuehn, 2007, p. 576). The academy also warns physicians to

reveal that cord blood banks are making unsubstantiated

claims promising future benefits of cord blood transplantation.

The exception to the recommendation for private banking is in

the case of a full sibling having a medical condition that could

benefit from cord blood transplantation. Here, the physician is

encouraged to recommend private cord blood banking (AAP).

The AAP’s stance is different regarding public cord blood

banking in that the academy encourages physicians to recom-

mend public banking. In fact, it strongly encourages targeted ef-

forts toward recruiting minority and underserved populations,

such as African Americans, Hispanics, American Indians and

Alaskan Natives. This is because these populations do not have

sufficient stocks of cord blood in public banks, so it’s currently

less likely that a minority individual will find a close match,

thereby decreasing access to a potentially lifesaving treatment.

The academy does encourage physicians to clearly explain to

families that the stem cells donated publicly would not be avail-

able for future personal use (AAP, 2007).

As much as 71 percent of public cord blood donations is rejected due to the rigorous testing that occurs on the blood

June July 2009 Nursing for Women’s Health 221

tions. It recommends private banking when there is a sibling

with a disease that has previously been proven treatable with

umbilical cord blood or when the parent of the infant has a

disease that may be treated with that child’s cord blood and an

HLA-antigen match exists. Storage for personal use is not rec-

ommended due to the small probability, as low as 0.04 percent,

of using one’s own cord blood in the first 20 years of life (Bal-

len, Barker, Stewart, Greene, & Lane, 2008).

The US government is even getting into the field of cord

blood banking, attempting to encourage public banking and

further research. It passed the Stem Cell Therapeutic and Re-

search Act of 2005, allowing the Secretary of Health and Hu-

man Services to enter into one-time contracts with public cord

blood banks and encouraging the collection of 150,000 new

units of cord blood from ethnically and genetically diverse in-

dividuals. The cord blood units that meet federal standards are

to be made available at transplant centers, and the units collect-

ed that do not meet federal standards for clinical use, are to be

made available for cord blood research (Stem Cell Therapeutic

and Research Act, 2005).

The National Marrow Donor Program (NMDP), an or-

ganization that has a registry to match potential marrow

or blood cell public donors and recipients, noted that the

number of cord blood transplants facilitated by NMDP has

doubled the past few years, making the total number of cord

blood transplants rise above 2,000. Kathy Welte, the direc-

tor of NMDP Center for Cord Blood, stated in a news release

that, “Increased donations to the public banks can help meet

the growing need for unrelated cord blood units” (NMDP,

2008, p. 1). Overall, the NMDP’s mission is to have health

care providers educate their patients regarding public cord

ACOG recently revised its opinion on cord blood banking

(ACOG, 2008) and it published a news release advising physi-

cians to give “balanced” information to pregnant patients. It

advised discussions about advantages and disadvantages of

private versus public banks, and advised notifying parents that

uncertainty exists over how long cord blood can successfully be

stored. Moreover, ACOG suggested that a physician who is in-

volved in recruiting patients for private banking should disclose

the conflict of interest upfront. Anthony R. Gregg, MD, chair of

ACOG’s Committee on Genetics, stated that “patients need to

be aware that the chances are remote that the stem cells from

their baby’s banked cord blood will be used to treat that same

child—or any other family member—in the future” (ACOG,

p. 476). Overall, ACOG takes no position for or against cord

blood banking, but instead recommends thorough education

when patients question health care providers (ACOG).

The WMDA is a voluntary organization created to repre-

sent cord blood banks, stem cell registries, interested organiza-

tions and others involved with stem cell transplantation. This

association released a policy statement in 2006 stating that,

“The likelihood that an autologous cord blood unit will be

used for transplantation is very low. There is currently no clear

proof that these cells will be able to be used for regenerative

medicine or to treat other diseases in the future. … Public cord

blood banking should be supported by national governments”

(WMDA, 2006, p.1). Thus, this association has views similar to

the previously mentioned organizations, discouraging private

banking, yet encouraging public cord banks that are based on

altruistic and voluntary banking.

The ASBMT published a committee report in 2008 recom-

mending public donation whenever possible, with two excep-

222 Nursing for Women’s Health Volume 13 Issue 3

ConclusionMany organizations recommend public cord blood banking

for all individuals, but recommend private banking only for

certain situations. Regarding private cord blood banks, each

organization expresses concern over the marketing strategies

and exaggerated claims that are made in popular media. Most

say that private banks target parents who have a relatively short

time to make an informed decision, plus make parents think

that this “biological insurance” is necessary. Only in the case

of an infant’s parent or sibling needing the cord blood do the

cited organizations recommend private cord banking. There-

fore, those in the health care field should discuss umbilical cord

blood banking with all future parents in order to clear up mis-

conceptions and to allow informed choices to be made. The po-

tential benefits of cord blood banking and transplantation are

promising, and this is a topic women’s health care professionals

should be informed and updated about in order to educate par-

ents completely and accurately. NWH

ReferencesAmerican Academy of Pediatrics. (2007). Policy statement: Cord

blood banking for potential future transplantation. Pediatrics, 119, 165–170.

American College of Obstetrics and Gynecology (ACOG). (2008). Committee opinion #399: Umbilical cord blood banking. Ob-stetrics & Gynecology, 111, 475–477.

Ballen, K. K., Barker, J. N., Stewart, S. K., Greene, M. F., & Lane, T. A. (2008). ASBMT committee report: Collection and preserva-tion of cord blood for personal use. Biology of Blood and Marrow Transplantation, 14, 356–363.

Brunstein, C. G., Setubal, D. C., & Wagner, J. E. (2007). Expanding the role of umbilical cord blood transplantation. British Journal of Haematology, 137, 20–35.

Cord Blood Registry. (2008, August). [Advertisement]. American Baby, 49.

Cryobanks International. (2009). Donating cord blood—Step 1 of 2. Retrieved March 21, 2009, from http://www.cryo-intl.com/enroll/donating/

Fernandez, C. V., Gordon, K., Van den Hof, M., Taweel, S., & Baylis, F. (2003). Knowledge and attitudes of pregnant women with re-gard to collection, testing and banking of cord blood stem cells. Canadian Medical Association Journal, 168, 695–698.

Garderet, L., Dulphy, N., Douay, C., Chalumeau, N., Schaeffer, V., Zilber, M. T, et al. (1998). The umbilical cord blood T-cell rep-ertoire: Characteristics of a polyclonal and naïve but completely formed repertoire. Blood, 91, 340–346.

Gluckman, E., Broxmeyer, H. A., Auerbach, A. D., Friedman, H. S., Douglas, G. W., Devergie, A., et al. (1989). Hematopoeitic reconstitution in a patient with Fanconi’s anemia by means of

blood banking in order to increase the size and diversity of

the NMDP registry. Currently, the NMDP registry has more

than 72,000 cord blood units in the United States, and an ad-

ditional 220,000 available from international banks, so this

organization is providing a beneficial service to those in need

of cord blood. It believes in public cord blood banking be-

cause only approximately 30 percent of patients in need of

cord blood or marrow will find a suitable match in their fam-

ily, leaving 70 percent needing an unrelated donor’s stem cells

(NMDP). It’s beneficial for those in health care to be aware of

this organization and what it offers.

Practical ImplicationsHealth care providers need to offer unbiased and complete in-

formation to patients. If parents decide to bank blood privately,

health care providers can provide the following tips guiding

parents in their choice of which bank to use. The bank cho-

sen should be accredited by the American Association of Blood

Banks (AABB) and should be financially stable to ensure fu-

ture access. Parents should ask banks what would happen to the

banked blood if their company went out of business. Because

geographic location can affect the stability of banks, choosing a

bank in a location that would not be impacted by earthquakes,

hurricanes or other natural disasters could be beneficial. Ide-

ally, the bank should specialize in processing and storing only

stem cells rather than collecting other additional human tissue,

in order to prevent cross contamination. Finally, researching

published data on the successes of each bank is vital (Kennen,

2004). The Parents Guide to Cord Blood Foundation (2008a)

provides statistics on the successful transplant numbers, costs

and other beneficial information for parents and has a use-

ful Web site (see Get the Facts). For private banking, parents

are paying a large upfront fee in addition to a yearly payment,

so the right blood bank should be carefully selected to ensure

quality and potential success.

If parents decide to bank blood publicly, health care provid-

ers can provide references and Web resources for parents to re-

search. The Parents Guide to Cord Blood Foundation (2008b)

lists hospitals that participate in public cord blood banking.

If individuals live in an area without a participating hospital,

Cryobanks International (2009) can be contacted at 1-800-

869-8608 or online (see Get the Facts). Individuals can also

call the National Marrow Donor Program at 800-627-7692 or

online (see Get the Facts).

Health care providers must inform patients that not every

family can donate publicly due to certain genetic, immunologic

and other factors. Also, patients should be encouraged to ask if

their health care providers will charge a fee for collecting cord

blood for public use. This is a generous donation, but one that

requires research and careful consideration.

http://nwhTalk.awhonn.org

June July 2009 Nursing for Women’s Health 223

Kobayashi, R., Ariga, T., Nonoyama, S., Kanegane, H., Tsuchiya, S., & Morio, T., et al. (2006). Outcome in patients with Wiskott-Aldrich syndrome following stem cell transplantation: an analy-sis of 57 patients in Japan. British Journal of Haematology, 135, 362–366.

Kobylka, P., Ivanyl, P., & Bruer-Vriesendrop, B. S. (1998). Preserva-tion of immunological and colony-forming capacities of long-term (15 years) cryopreserved cord blood cells. Transplantation, 65, 1275–1278.

Krivit, W. (2004). Allogeneic stem cell transplantation for the treat-ment of lysosomal and peroxisomal metabolic diseases. Springer Seminars in Immunopathology, 26, 119–132.

Kuehn, B. M. (2007). Pediatric group recommends public cord blood banking. Journal of the American Medical Association, 297, 576.

McCullough, I., & Clay, M. (2000). Reasons for deferral of poten-tial umbilical cord blood donors. Transfusion, 40, 124.

Moise, K.J. (2006). What to tell patients about banking cord blood stem cells. Contemporary OB/GYN, 51, 42–52.

National Marrow Donor Program (NMDP). (2008). NMDP com-mends ACOG recommendations to educate physicians, expectant parents on cord blood banking. Retrieved March 21, 2009, from http://www.marrow.org/NEWS/News_Releases/2008/acog_guidelines_0206.html

Parents Guide to Cord Blood Foundation. (2008a). Tables of private bank features & pricing. Retrieved March 21, 2009, from http://parentsguidecordblood.org/content/usa/banklists/summary.shtml

Parents Guide to Cord Blood Foundation. (2008b). Public cord blood banks in the USA. Retrieved March 21, 2009, from http://www.parentsguidecordblood.org/content/usa/banklists/ publicbanks_new.shtml?navid=14

Pasquini, M. C., Logan, B. R., Verter, F., Horowitz, M. M., & Niet-feld, J. J. (2005). The likelihood of hematopoietic stem cell trans-plantation (HCT) in the United States: Implications for umbilical cord blood storage. ASH Annual Meeting Abstracts, 106, 1330.

Rocha, V., Cornish, J., Sievers E. I., Filipovich, A., Locatelli, F., & Peters, C., et al. (2001). Comparison of outcomes of unrelated bone marrow and umbilical cord blood transplants in children with acute leukemia. Blood, 97, 2962–2971.

Rocha, V., & Locatelli, F. (2008). Searching for alternative hemat-opoietic stem cell donors for pediatric patients. Bone Marrow Transplant, 41, 207–214.

Schoemans, H., Theunissen, K., Maertens, J., Boogaerts, M., Ver-faillie, C., & Wagner, J, et al. (2006). Adult umbilical cord blood transplantation: A comprehensive review. Bone Marrow Trans-plantation, 38, 83–93.

Stem Cell Therapeutic and Research Act of 2005. (2005). Re-trieved on March 21, 2009, from http://www.nationalcordblood program.org/cord blood public law 109-129 (2).pdf

Viacord. (2008, August). [Advertisement]. American Baby, 22–23.

World Marrow Donor Association. (2006). WMDA Policy State-ment on the Utility of Autologous or Family Cord Blood Unit Stor-age. Retrieved March 21, 2009, from http://www.worldmarrow.org/fileadmin/WorkingGroups_Subcommittees/Cord_Blood_ Working_Group/WMDA_Policy_Statement_Final_02062006.pdf

umbilical-cord blood from an HLA-identical sibling. New Eng-land Journal of Medicine, 321, 1174–1178.

Jacobsohn, D. A., Hewlett, B., Ranalli, M., Seshadri, R., Duerst, R., & Kletzel, M. (2004) Outcomes of unrelated cord blood trans-plants and allogeneic-related hematopoietic stem cell trans-plants in children with high-risk acute lymphocytic leukemia. Bone Marrow Transplantation, 34, 901–907.

Jaing, T. H., Hung, I. J., Yang, C. P., Chen, S. H., Sun, C. F. & Chow, R. (2005) Rapid and complete donor chimerism after unrelated mismatched cord blood transplantation in 5 children with beta-thalassemia major. Biology of Blood and Marrow Transplantation, 11, 349–353.

Johnson, F. L. (1997). Placental blood transplantation and autolo-gous banking: Caveat emptor. Journal of Pediatric Hematology & Oncology, 19, 183–186.

Kennen, R. (2004). Cord blood banking: Making an informed choice. International Journal of Childbirth Education, 19, 19–21.

Kline, R. D. (2001). Whose blood is it, anyway? Scientific American, 4, 42–49.

Get the Facts

American Academy of Pediatrics

http://www.aap.org/advocacy/releases/ jan07cordbloodfaq.htm

American Association of Blood Banks

http://www.aabb.org/

Cryobanks International

http://www.cryo-intl.com/

National Marrow Donor Program

http://www.marrow.org/

Parents Guide to Cord Blood Foundation

http://parentsguidecordblood.org/content/usa/aboutus/index.shtml?navid=1