Cord clamping, blood banking…

small_4424101920A friend asked me what my current understanding of the value of cord blood banking was and whether there was a resource I would recommend to women who were wanting to read more about the pros and cons of this.  As is often the case in commercial ventures, the marketing materials produced by those charging for such services tend to over-emphasise the selling points, sometimes spinning data in a rather emotive fashion.  It is then perhaps inevitable that many of us who work with women and babies do not view those supposed advantages in quite the same way and are instead more likely to seek to redress the balance and stress the disadvantages, especially where (as in this case) they are direct and potentially invasive as far as interrupting normal physiology is concerned.  Having shared my thoughts with my friend, I thought it might be useful to share a few resources more widely…

One of my go-to resources on the topic of cord blood banking is Sarah Buckley‘s (2009) book, Gentle birth, gentle mothering.  Sarah finds that there is little chance that this kind of ‘biological insurance’ will ever be used by the parents who pay for this service.  This was also the position taken in the RCOG’s information for parents leafletNadine Edwards and I wrote about optimal cord clamping and related topics in Birthing Your Placenta.

Your guide to the issues and the evidence relating to the birth of the placenta.

All of the above resources that take a position agree that it is difficult to recommend cord blood banking for many reasons.  Unless there is already a known medical need for cord blood (i.e. in a close family member), the chances of it ever being used are remote. It is also an expensive process which carries no guarantees; the success of collection is dependent on a number of factors outside of anyone’s control, contamination is hard to eradicate and current storage methods and facilities may not ensure prolonged viability. Sarah, Nadine and myself go somewhat further than the RCOG in stressing the way in which the process of cord blood banking, whether for private or public ends, can interfere with normal physiology and deprive the baby of its own blood.  It is hard to justify taking away something that the newborn baby can definitely use now just in case the baby or someone else might be able to use it later.

 

Here’s an updated version of an article that I wrote on this, which was first published in 2007.

 

Cord blood banking: who benefits?

The concept of harvesting cord blood for possible use in disease treatment has been receiving more publicity of late. This is partly because charities now offer a more altruistic means of collecting, transporting and storing a baby’s cord blood for possible future use than the more established private companies. Trusts have developed guidelines for staff, and midwives are increasingly likely to need this guidance as they encounter parents who want to add another element to the third stage of labour. Many are distressed, however, at the way in which representatives from these charities are, in some hospitals, allowed to ‘lie in wait’ outside the labour ward and hassle parents to donate their cord blood on their way in. As one new father put it, “It’s a bit like when you open your front door and find a charity worked asking for money, except that your wife’s in pain and you’re unprepared to say no.”

The issue of taking cord blood at birth has always been controversial. In 1999, on the grounds that (a) there were no accurate estimates of how many children would benefit from having their cord blood stored and (b) “there is no evidence on the safety or effectiveness of autologous cord blood transplantation for the treatment of malignant neoplasms”, the American Academy of Pediatrics concluded that, “it is difficult to recommend that parents store their children’s cord blood for future use” (116). In 2006, the RCOG Scientific Advisory Committee reviewed this area and, while in favour of an NHS cord blood bank, is “unconvinced of the benefit of personal commercial banking for low-risk families” (4), while The Lancet (2007) described the Virgin Health Bank as an “exciting new initiative” (437) and accused NHS staff of being unresponsive to parent choice.

Public cord blood banking may partially address the ethical dilemma of whether it is acceptable for parents to store cord blood for the use of their family alone, or whether – like with blood donation generally – this resource should be freely available to all, yet other ethical questions remain. Who owns cord blood? Should NHS midwives spend time collecting cord blood and filling out the attendant paperwork if this means that other women then get less of their time? What about the emotive adverts which stress the possibility of future risk to the health of babies and which may prey upon the worries of pregnant women? After all, the chances of a baby needing money for university are far greater than the chances of the same baby ever having need of stem cells. And should companies and charities be allowed to hassle parents at the labour ward door?

 

A no-risk option?

For me, a bigger concern is the almost throwaway line that appears in a number of the articles which discuss this area. They claim that cord blood banking carries no risk to mother or baby. Yet in fact a number of possible risks exist, not least of which involves disruption to the third stage of labour and those important first few minutes after birth. Indeed, a degree of disruption is inevitable because the blood needs to be collected as soon as possible, and ideally while the placenta remains in utero. Cord blood collection is not always compatible with a physiological third stage of labour; certainly not if you respect physiology and the need for warmth, quiet and privacy. It can also delay active management, and it may lead to inaccurate cord blood sampling if this is needed. On top of this, the attendant who is focused on the somewhat complex cord blood collection procedure is inevitably then less focused on the wellbeing of the woman and her baby (RCOG 2006).

Besides, isn’t the third stage debate still ongoing? Even the RCOG (2006) now acknowledges that early cord clamping is detrimental, although admittedly they are primarily concerned with premature babies’ need for their cord blood. Sarah Buckley’s (2005) consideration of the evidence on early cord clamping led to her suggesting that cord blood collection is fairly illogical in that we are removing blood to treat a possible (but unlikely) future problem at the very point when babies need to choose how much of their blood they need for themselves. The cord blood banking companies often point out that cord blood would otherwise be discarded, yet this statement assumes that all women would choose a managed third stage with early cord clamping and thus removes a whole set of options from the picture.

 

The bigger picture of choice

When I talk about anti-D, I often share my fascination with the fact that it is given to a person who doesn’t directly benefit from it, for the possible benefit of a person who doesn’t yet exist. The notion of cord blood banking offers another similarly interesting paradox. Unless a family member is already ill (and that’s a whole new can of worms), here we have a procedure that takes a substance from a person who needs it at the time, on the basis that there is a tiny possibility that they or someone else might need it later on in life.

I realise that, like others who have questioned cord blood banking, I may be accused of attempting to deny choice. In fact, my intention is the very opposite. By all means, let’s support those parents who want to explore this option, but surely they have a right to consider all of the benefits and risks involved? And, ideally, before they get hassled in the corridor to the labour ward.

 

This is an older article. For up-to-the-minute updates on new birth-related research and thinking, jump on my newsletter list!

A version of this article was originally published as Wickham S (2007). Cord Blood Banking: Who Benefits? TPM 10(7):42.

 

References

AAP Work Group on Cord Blood Banking (1999). Cord Blood Banking for Potential Future Transplantation: Subject Review. Pediatrics, 104 (1): 116-18

Buckley, S (2005). Gentle Birth, Gentle Mothering. One Moon Press, Brisbane.

RCOG (2006) Umbilical Cord Blood Banking. Scientific Advisory Committee Opinion Paper 2. RCOG, London.

The Lancet (2007) Umbilical cord blood banking Richard Branson’s way. Lancet, 369 (9560), pp. 437.

heart i-cord photo credit: Salihan via photopin cc

3 comments for “Cord clamping, blood banking…

  1. November 29, 2014 at 5:26 pm

    As a midwife and mother, I fully understand the reasons why women may chose a physiological third stage – indeed when I birthed my last baby in 1999, I insisted on it and enjoyed the experience. However there will also be those who, for whatever reason, wish to investigate the possibility of cord blood banking and so I felt it was my responsibility to research this complicated subject in more detail. The resulting overview of cord blood banking was published in 2008 and it might help you to better understand all aspects of this topic. In it I say:
    “The field of UCB donation is relatively new and it raises emotive ethical, medical, scientific and social issues. For practising midwives, their prime consideration must always be to provide optimal care for the mother and her baby. The Midwives Rules (NMC 2004) states: “Except in an emergency, a practising midwife shall not provide any care or undertake any treatment which she has not been trained to give”.
    The collection of UCB during or after the third stage of labour could be complicated by a series of factors including: multiple birth, prematurity, the cord around the neck, risk of post partum haemorrhage or emergency caesarean section. Furthermore, it has the potential to disrupt the initial period of bonding when skin-to-skin contact and early breastfeeding should be allowed to progress unhindered.”
    You can read the full article here:http://www.sharontrotter.org.uk/midirs2008.htm

  2. Susan Carroll
    July 15, 2016 at 5:00 am

    I wish I had known this before the births of my 6 babies. But my daughters can still benefit. Thank you… With horse births attended by vets, sometimes the foal gets “the staggers”, a condition where the foal is slow to stand, and wanders around not able to find his mama’s teat for a prolonged period. Turns out this does not happen without a vet there. Why? Because the vet clamps the cord immediately. Normally the cord is only broken by the movement of the mother and foal after a period of time. Foals with staggers have low oxygen and iron levels because they did not get enough blood from the placenta and cord. This has been found in the last decade.

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.