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: [email protected].
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