Photo: Archie Rigney and his mother Azure – effective placental transfusion results in an empty, white umbilical cord

When I was a bright-eyed and bushy-tailed student midwife, I was awarded a certificate and a box of chocolates. My achievement was collecting the most 'cord' blood in the hospital. At that time, the Local Health District was trialling a 'cord' blood bank. The collected blood was to be used for treating leukaemia and for research. Every woman birthing in the hospital was asked to donate 'cord' blood for the good cause, and many generously agreed. I was exceptionally good at collecting the blood. This post is a small attempt to repent for my sins now that I know better.

'Cord' blood is baby's blood

The term 'cord blood' is misleading. The blood collected via the umbilical cord is the baby's blood. When adults donate blood it is collected via their arm. We don't refer to that blood as 'arm blood'.

During pregnancy, the baby and placenta share the baby's circulating blood. The placenta provides an extension of the baby's circulation. This allows the baby to receive nutrients and oxygen from the intervillous space between the (separate) mother's circulation and the placenta. After birth, the placental circulation alters, sending all the baby's blood into their body. You can read more about the 'physiology of newborn transition' in this this post and more about transfusion by the placenta in this movie:

Knowledge about the short-term and long-term health benefits of the baby having their full blood volume at birth is now widespread (see this post for details).

The importance of stem cells for the baby

Stem cells can self-renew (make copies of themselves) and differentiate (develop into more specialised cells). At birth, babies have haematopoietic stem cells in their blood. This type of stem cell is similar to those found in bone marrow and can regenerate red blood cells and immune system cells. The likelihood is that these stem cells play an important role in repairing any damage done during birth. They may also play a role in longer-term protection from disease.

The business of collecting babies' blood

Companies are targeting parents and making big money by removing and storing their baby's blood. Care providers are also making money from recruiting parents and collecting blood for these companies. The sales pitch is: if your baby develops a particular type of illness in the future, you may be able to use their stored stem cells as treatment. These companies are increasingly sponsoring care provider organisations and events, and buying endorsements from obstetricians and midwives. I have even been approached to endorse their services several times—clearly, they had not read this post.

My primary concern with 'cord' blood banking is the misleading information given to parents. This misinformation raises both ethical and legal issues. Two main areas require further clarity: blood collection volumes and cord clamping and the effectiveness of stem cell treatments.

Blood collection volumes and cord clamping

Parents need to be informed that collecting blood from the umbilical cord requires premature cord clamping and that the blood being collected belongs in the baby's body

Paediatric guidelines state that 'blood draws in infants and children should not exceed 5% of the total blood volume in any 24-hour period'. A 3.6kg newborn has a blood volume of around 280mls, so the maximum blood draw is 14mls. 

A collection bag holds a significant proportion of the baby's blood. The collection bags for 'cord' blood hold 250mls (35mls already taken up with anticoagulant fluid). The minimum amount of blood acceptable for collection is 45mls, and the maximum possible is 215mls. In one procedure guide, it states "collect as much cord blood as possible [in bold]." Another company reports that the median volume they collect is 60mls. I wonder how many parents would consent to someone coming onto the postnatal ward and sticking a needle into their baby to collect 6 adult vials of blood? Cord blood collection is the equivalent to this, only the needle is in the umbilical cord rather than the baby.

In response to publicity about the importance of 'delayed' cord clamping aka 'optimal' cord clamping. The latest marketing ploy is to tell parents they can have both 'delayed' cord clamping and collect 'cord' blood. Some websites even include a page on the benefits of 'delayed' cord clamping. They define 'delayed' as 30 seconds to 1 minute. However, it usually takes longer than this for the full blood volume to transfer. If all the baby's blood has transferred into the baby – however long that takes for that individual baby – then there is minimal, if any, blood left to collect. Look at the picture at the top of this post. If you can get blood out of that cord you deserve a certificate and chocolates! At least one website acknowledges this, and states that the risk of 'delayed' cord clamping is "reducing the volume of a cord blood collection such that it cannot be banked...". Note that public cord banks require even larger volumes of blood than private.

In contrast, one company refers specifically to 'optimal' cord clamping ie. waiting until the cord is white. They suggest that their company can effectively process 10-20mls of 'cord blood'. I have requested evidence of that claim eg. photos or a movie of the collection from a white cord, and further information about the effectiveness of a small sample (most other companies state that effective processing for storage is determined by the size of the sample). I am still waiting.

In the meantime, a baby blood company amended their promotion blog after being called out by the BBC for its misleading claims.

The effectiveness of stem cell treatments

Parents need to be informed about the lack of evidence regarding the usefulness of cord blood for future treatment of their baby

There is currently no research evidence demonstrating the effectiveness of 'cord' blood stem cells (haematopoietic) in the treatment of disease or disability. Many company websites hint at this by using the terms 'potential' or 'may' or 'future' or 'hope to'. Sites also claim that 'cord' blood stem cells are being used to treat '80 diseases', with no mention of whether those treatments are effective or not. Some sites refer to the treatments as 'alternative' ie. not being used in mainstream medicine. However, others include claims of successful treatment, citing case studies or anecdotal news articles (often about stem cells in general rather than 'cord' blood specifically). In addition, all of the research (I can find) is being conducted on 'public' stem cells ie. used to treat strangers rather than the baby who donated, or their family.

I was recently in correspondence with a representative of a cord blood company and asked for some research evidence to support his claims of successful treatments. He sent me a collection of unreferenced statements (marketing) on the company website and two feasibility studies. Feasibility studies are carried out to demonstrate that a treatment is 'safe', and a study is possible. They do not test the effectiveness of a treatment. I pointed this out and have not heard back. Whilst there may be several trials underway with 'public' donations, I am yet to see any actual results relating to 'cord' blood stem cells and treatments. Send me any you may have (research articles only please).

In 2004 The European Commission released a press statement about this situation stating:

If commercial cord blood banks are allowed, appropriate information should be given to the consumers willing to use their services, including the fact that the likelihood that the sample may be used to treat one's child is currently negligible, that the future therapeutic possibilities are of a very hypothetical nature and that up until now there is no indication that the present research will lead to specific therapeutic application of one's own cord blood cells. Therefore, information has to be particularly explicit that the auto conservation has little value in the current state of scientific knowledge. This information should be made clear on all media, including Internet, and in any contracts linking commercial banks to their customers.

Twenty years later, the British Medical Journal published an article raising concern over the claims made for stem cell applications. So, over a 20 year period, companies have been profiting from collecting and storing baby's blood without evidence that it will be of any use.

Companies have also started offering umbilical cord tissue collection as an alternative, or in addition, to 'cord' blood collection. Umbilical cord tissue contains mesenchymal stem cells and can be collected alongside optimal cord clamping. However, there is no evidence that this type of stem cell offers effective treatments either.

Summary

I am not suggesting that baby blood banking shouldn't be an available option. I am suggesting that parents need adequate information before they decide to remove a significant amount of their baby's blood volume. They need to weigh up the known benefits of full blood volume at birth vs an unlikely treatment for an unlikely future illness. Cord blood is babies' blood. Parents also need to know if their care provider will benefit financially from persuading them to collect and bank blood.

PS: I no longer participate in stealing babies' blood. We live and learn.

Further resources

You can find more information on this topic in my books and Reclaiming Childbirth Collective lessons.

I also discuss the topic in an episode of The Midwives' Cauldron – Placentas and Cord Blood