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Analysis

Guidance paper 1a: Commercial umbilical cord blood collection

1 July, 2008

Guidance paper 1a: Commercial umbilical cord blood collection

Over the last decade, there have been key improvements in identifying and treating the causes of perinatal mortality and morbidity. Research and the development of some healthcare technologies has enabled clinicians to gain better knowledge and understanding of most genetic conditions in pregnancy.

 

Midwives magazine: December 2002

 

Introduction

 

Over the last decade, there have been key improvements in identifying and treating the causes of perinatal mortality and morbidity. Research and the development of some healthcare technologies has enabled clinicians to gain better knowledge and understanding of most genetic conditions in pregnancy.

 

However, some conditions continue to cause and extract a significant toll in perinatal and infant mortality and morbidity. Scientific knowledge has helped to raise society’s expectations of the ‘perfect’ baby. This has placed extra demands on the health services to find new and more sophisticated ways of treating these conditions. The harvesting and storage of stem cells from umbilical cord blood is one such area that is attracting interest from parents in the UK. Stem cells are cells from which other types of cells can develop.

 

Within this paper, reference is made to blood stem cells, which perform the function of replenishing the supply of red blood cells, white blood cells, and platelets. Most of these stem cells are found in the bone marrow, peripheral blood and the placenta. Placental blood contains high concentrations of haemopoetic stem cells, which are needed to produce new blood cells.

 

Umbilical cord blood collection

 

Midwives have routinely collected umbilical cord blood after birth where the mother is known to be rhesus negative for a known haemoglobinopathy, such as sickle cell disorder, or for research purposes. Umbilical cord blood collection may also be recommended for a child where there is a familial history of genetic disorder, which may be treated by stem cell transplantation if the child develops the disease.

 

There is some evidence of the benefit of collecting donated stem cells from the cord blood of siblings for the treatment of acute lymphoblastic leukaemia where there is a genetic match. There are also instances where families may donate umbilical cord blood (altruistic donations) to other families with an unsuitable match. In such cases, donation is subject to informed consent and donors are required to undergo tissue typing and screening for hepatitis B and HIV before being accepted. Usually, one of the cord blood banking centres that holds a registry of donors and possible matches in the UK would make the appropriate arrangements for counselling and collection. This service is managed by the National Blood Service, which has collected umbilical cord blood samples since 1996.

 

Commercial umbilical cord blood collection

 

It is important to distinguish between medically indicated and commercial umbilical cord blood collection for stem cell harvesting, the latter being for profit. The practice of commercial umbilicalcord blood collection and stem cell harvesting is already popular in the US, where many parents see it as insurance against any future health problems their children may develop or storing a spare immune system for their children. This service is now being marketed to parents in the UK, for a cost of up to £800, and requires NHS midwifery support to collect the cord blood, which is sent to the company for harvesting and storage of stem cells.

 

Issues for consideration

 

While it is easy to understand the appeal of stem cell harvesting for parents, the practice also poses a number of questions and problems for midwives, parents, and NHS Trusts.

These include:

  • The procedure for collecting such samples is cumbersome and detracts from the primary important task of the midwife during the third stage of labour

  • The health and safety implications of introducing needles during the third stage of labour. For example, increased risk of needlestick injury

  •  It is not acceptable to expect midwives and NHS Trusts to be liable for any mishaps that may occur during a procedure that is not clinically indicated or recommended, such as (i) Failure in the process (ii) Insufficient blood collection (iii) Contamination of specimen (iv) Delay in transportation and storage.

 

The RCM position

 

The RCM does not support the commercial collection of umbilical cord blood on demand for stem cell harvesting. The RCM believes the current research evidence has not demonstrated that there is any value to be gained from the routine harvesting and storage of stem cells on demand, and that further research is needed in this area.

 

The RCM supports the collection of umbilical cord blood if medically indicated and for research purposes only. The RCM welcomes new technologies that enhance the quality of maternity care, and provide clear benefits for the great majority of women and their babies. Further, the introduction of new practices should not impact adversely on the quality of midwifery care or theimmediate care of the mother and newborn. While the RCM supports women’s informed choices and decisions, it believes that there is a need for a wider debate in the NHS on the ethical, legal and safety implications of introducing commercial initiatives into practice where there is insufficient evidence to support its benefits.

 

RCM recommendations

 

All midwives should acquaint themselves with the evidence and the issues around stem cell harvesting so that they can discuss the issues with women as appropriate. The routine collection of umbilical cord blood on demand is likely to have adverse impact on midwives’ ability to provide high quality care for the mother and infant in the third stage. Trusts should therefore consider whether they have the necessary resources to provide support for cord blood collection on demand. Directors of midwifery services/supervisors of midwives should discuss the legal and practice implications of both assisting and refusing to assist with umbilical cord blood collection on demand with Trust management and lawyers.

 

Maternity services should develop guidelines/ policies, which explicitly state that:

  • Midwives are not obliged to collect commercial umbilical cord blood samples

  • Midwives will not be held responsible for the quality or quantity of the sample collected or for delays in transportation or storage if they chose to assist the woman. Such information should be made available to all women and the companies involved

  • Supervisors of midwives should be involved in all discussions and the development of local guidelines

  • Maternity services should develop an information leaflet (in consultation with geneticists, neonatologists and obstetricians) to offer unbiased, evidence-based information on the indications for collecting cord blood.

 


 

Bibliography

 

Armitage S,Warwick R, Fehily D, Navarrete C, Contreras M. (1999) Cord blood banking in London: the first 1000 collections. Bone Marrow Transplant 24(2): 139-45. Gluckman E. (2001) Haematopoietic stem-cell transplants using umbilical cord blood. N Eng J Med 344: 1860. Royal College of Obstetricians and Gynaecologists. (2002) Umbilical Cord Blood Banking. Opinion Paper 2. RCOG: London. Available at: www.rcog.org.uk Ryan J. (2000) Cord blood storage; growing interest. The Practising Midwife 3(11): 30-31. Thomson JA, Itskovitz-Eldor J, Shapiro SS,Waknitz MA, Swiergiel JJ,Marshall VS, Jones JM. (1998) Embryonic stem cell lines derived from human blastocysts. Science 282(5391): 1145-7.

 

 

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