Parents' Knowledge, Awareness and Attitudes of Cord Blood Donation And

Peberdy et al. BMC Pregnancy and Childbirth (2018) 18:395 https://doi.org/10.1186/s12884-018-2024-6

RESEARCH ARTICLE Open Access Parents’ knowledge, awareness and attitudes of cord blood donation and banking options: an integrative review Lisa Peberdy1* , Jeanine Young1, Debbie Louise Massey1 and Lauren Kearney1,2

Abstract Background: For over 25 years cord blood has been used as an alternative to bone marrow for therapeutic use in conditions of the blood, immune system and metabolic disorders. Parents can decide if they would like to privately store their infant’s cord blood for later use if needed or to publicly donate it. Parents need to be aware of the options that exist for their infant’s cord blood and have access to the relevant information to inform their choice. The aim of this paper is to identify parent’s knowledge and awareness of cord blood donation, private banking options and stem cell use, and parent sources and preferred sources of this information. Methods: An integrative review was conducted using several electronic databases to identify papers on parents’ knowledge, attitudes and attitudes towards umbilical cord blood donation and banking. The CASP tool was used to determine validity and quality of the studies included in the review. Results: The search of the international literature identified 25 papers which met review inclusion criteria. This integrative review identified parents’ knowledge of cord banking and/or donation as low, with awareness of cord blood banking options greater than knowledge. Parents were found to have positive attitudes towards cord blood donation including awareness of the value of cord blood and its uses, with the option considered to be an ethical and altruistic choice. Knowledge on cord blood use were mixed; many studies’ participants did not correctly identify uses. Information sources for parents on cord blood was found to be varied, fragmented and inconsistent. Health professionals were identified as the preferred source of information on cord blood banking for parents. Conclusions: This integrative review has identified that further research should focus on identifying information that expectant parents require to assist them to make informed choices around cord blood banking; and identifying barriers present for health professionals providing evidence based information on cord blood use and banking options. Keywords: Cord blood banking, Cord blood donation, Cord blood stem cells, Women’s knowledge, Expectant parents’ knowledge, Information sources

Background the immediate period after the birth of a baby. Cord blood For over 25 years cord blood has been used as an alterna- can be collected and stored either publicly or privately. tive to bone marrow for therapeutic use in conditions of Public cord blood banks operate in all developed the blood, immune system and metabolic disorders [1]. countries, and within most developing countries. By Cord blood is now one of the main haematopoietic stem 2014, the international cord blood banking network cell sources [2]. Umbilical cord blood banking is the comprised over 160 public cord blood banks in 36 coun- process of collecting and storing umbilical cord blood, in tries, with over 731,000 umbilical cord blood units stored [3]. Public cord blood banks collect, transport, process, test and store cord blood units which have been altruistically donated for allogeneic use, at no financial * Correspondence: [email protected] – 1School of Nursing, Midwifery and Paramedicine, University of the Sunshine cost to the donating parents [4 9]. The donated cord Coast, Locked Bag 4, Maroochydore DC, QLD 4558, Australia blood unit is not reserved for the use of the donating Full list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Peberdy et al. BMC Pregnancy and Childbirth (2018) 18:395 Page 2 of 21

family, who relinquish their rights of ownership of the banking was reported to have commenced in 1991 [18]; blood to the banking facility [10]. no papers were found on this topic prior to 1998. Private cord blood banks charge parents a fee for the collection, processing and storage of their infant’s cord blood Inclusion and exclusion criteria for exclusive autologous or family use [4, 8, 9, 11, 12]. Some Inclusion criteria for the review consisted of original re- private cord blood banks now also store cord tissue. search studies that investigated and reported parents’ Parents can decide if they would like to privately store knowledge, awareness and attitudes of cord blood dona- their infant’s cord blood for later use if needed, publicly tion and banking options, written in the English lan- donate it, defer cord clamping to allow their infant to re- guage. The initial search was conducted by the first ceive optimal volumes of cord blood at birth or to dis- author who identified the potential studies for inclusion card the remaining cord blood with the placenta after based on title and abstract, with all papers for inclusion birth. Parents need to be aware of the options that exist discussed and agreed upon by co-authors. for their infant’s cord blood and have access to the rele- Exclusion criteria included papers not available in the vant information to inform their choice. Parents’ know- English language, discussion papers, papers reporting on ledge and understanding of cord blood banking and knowledge and awareness of embryonic stem cells, and donation has been reported to be low and little is known papers which reported only on women’s choices and rea- about their source of information on this topic and the sons for choice. quality of the information provided [13–15]. Thus, ac- Figure 1 details the structured search conducted, in- curacy of information is difficult to assess and there is cluding the search strategy and inclusion process applied limited understanding of how parents use this informa- to the peer reviewed literature which was included in tion to inform their decision making about cord blood this integrative review. banking and donation. Data evaluation Methods Each article was read and summarised to identify the key Aim points and common themes. Following the identification In this integrative review, we aimed to identify a) par- of these, the similarities and differences between studies ent’s knowledge and awareness relating to cord blood were compared. Critical Appraisal Skills Programme donation, private banking options and stem cell use; b) (CASP) tools appropriate for the study designs were used sources of information received, and c) parents’ percep- to determine the quality of the studies [19]. Quantitative tions of appropriate sources and personnel to provide studies were assessed using the CASP Cohort Study this information. The rationale for the integrative review Checklist (see Additional file 1). Qualitative and mixed was to identify gaps in knowledge and to provide direc- methods studies were assessed using the CASP Qualitative tion for the development of antenatal education frame- Checklist (see Additional file 2). No papers were excluded works for parents in this important and evolving field of because of their validity or quality. cord blood banking and cord blood use. Data analysis A total of 31 articles were retrieved that provided descrip- Methodology tion relating to parents,’ expectant parents’ or pregnant The integrative method chosen for this review allowed for women’s knowledge and awareness of cord blood banking rigorous evaluation of the strength of the evidence from a and donation. Only one paper retrieved also explored combination of diverse methodologies (Whittmore and pregnant women’s and/or expectant parents’ knowledge Knafi 2005), and identification of gaps in the literature and awareness of cord tissue banking [20]. Six papers were and areas for further research [16]. The five stages model excluded because they did not meet the inclusion criteria, [17] of problem identification, literature search, data or aims of this integrative review [11, 21–25]. evaluation, data analysis, and presentation [16], was used Thematic analysis [26] was used to identify emerging as a framework to guide this integrative review. domains and themes in the literature, with three common domains identified: cord blood banking options, Literature search cord blood uses, and information sources. Databases searched included PubMed, Scopus, MIDIRS, CINAHL and Google Scholar using search terms: cord Findings blood banking, cord blood donation, cord blood stem This search of the international literature identified 25 cells, women’s knowledge, expectant parents’ knowledge, papers of parents, pregnant women’s and expectant par- parent/parental knowledge, sources. Publication date ents’ knowledge and awareness of cord blood banking limits were set between 1991 and July 2017. Cord blood and donation which met the review inclusion criteria Peberdy et al. BMC Pregnancy and Childbirth (2018) 18:395 Page 3 of 21

Fig. 1 Peer Reviewed Literature Screening and Inclusion Process

[13–15, 18, 20, 27–46]. Studies selected for inclusion in the Three domains pertaining to pregnant parents’ know- review included empirical studies using qualitative (n =5), ledge, awareness and attitudes were identified: a) cord quantitative (n = 18) and mixed methodologies (n =2). blood banking and donation; b) cord blood use; and c) Overall, papers exploring pregnant women’s and expectant cord blood information sources and preferred informa- parents’ knowledge and awareness of cord blood donation tion sources. Cord blood banking and donation options and banking, were conducted in 15 countries: North Amer- encapsulated three themes: knowledge, awareness and ica and Canada [13, 15, 18, 27, 28, 31], Europe and the attitudes. The second domain, cord blood use, com- United Kingdom [14, 29, 30, 32, 34, 36, 41, 42, 46], Australia prised two themes: knowledge and awareness. The final [40], Asia and the Middle East [33, 35, 37, 43–45], Africa domain, information sources, was also divided into two [38, 39] and one international study involving countries in themes: actual sources and preferred sources of informa- Europe, Asia, Australasia, the Americas and Africa [20]. tion on cord blood banking and donation. This integrative review included descriptive quantitative studies predominantly using survey designs [13–15, Cord blood banking and donation 20, 22, 30, 33–36, 39–43, 46]; qualitative studies pre- Seven papers investigated and reported on cord blood dominantly comprising focus groups and interviews banking awareness [13, 15, 31, 39–41, 46]. Four studies re- [18, 27–29, 31, 37]; or mixed method approaches using a ported a high level of awareness, with around 70% of par- survey design with interviews and focus groups [32, 38]to ticipants reporting awareness of the topic [15, 40, 41, 46]. describe knowledge, awareness and attitudes of cord blood Women of lower education levels, age 25 years or less, or donation and banking options. Table 1 summarises the pa- of an ethnic minority background were factors associated pers included in this review. with less awareness of banking and donation [15, 40]. Peberdy Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

1 Mathevic & To investigate awareness, Croatia 960 women Quantitative Overall: Preference of Strength: Large Childbirth and Pregnancy BMC al. et Erjavec (2016) level of knowledge, 2 Maternity OPD 96% response rate Questionnaire voluntary donation. One-third sample size in attitudes and information opted for private donation. two hospitals partly sources of pregnant women 50% pregnant women who representative of and hospital maternity staff were not planning on CCB city population. about cord blood banking. this pregnancy most often Weakness: Participant stated insufficient knowledge demographics and too much paperwork representative of Knowledge and awareness: urban not general Increases with age, education population, although level and pregnancy duration. UCB mainly performed Majority unaware of in urban populations practical information. Validation of tool Information sources: Media not disclosed

main source; 6% from Obs; (2018)18:395 nil from other HPs 2 Matsumoto et al. To investigate public Jordon 899 women Quantitative Overall: Positive public Refusal rate (2016) opinion and knowledge 6 Maternity Hospitals 100% return rate Questionnaire: multi opinion about CBB. Most not recorded about cord blood banking (4 Private, 2 Public) Convenience sample choice, Likert-scale, wanted more information Not all questions in Jordon. Maternity OPD and coded short on CBB, especially from Obs. answered fully answer format. Knowledge & awareness Tool developed and *69% reported low administered knowledge of by authors. CBB & transplant *77% reported low knowledge of CBD *Higher education & household income = more likely to hear/discuss CBB with Obs. *Only 7% heard about CBB from Obs Attitudes and opinions *CBD supported more than CBB; Higher likelihood of CBB if presented with future potential or recommended by Obs *Women with prior knowledge about CB transplants found it ethical /more willing to do CDB Preference and information *66% want more CBB information *71% Obs preferred information source 3 Kim et al. To assess Korea 320 early Quantitative Overall: CBD decided earlier Lacked thorough (2015) the knowledge & 3 metropolitan post-partum 2 Questionnaires, yes/no than CBB. Mass media most examination on 21 of 4 Page attitude of early post-partum maternity hospitals women who answer format for knowledge influential factor for CBD delivery of women in had stored assessment; 4 point scale for Reasons for CBB/CBD *93% CB education Korea with regard (n = 109), attitude format. Tools adapted CBB - as insurance for baby. Some participants to storage, donated from 2 previous studies *73% CBD - due to unlimited believed they Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

donation & disposal (n = 34), Kim et al. (2009) and Lee (2006) uses of CB were educated Childbirth and Pregnancy BMC al. et of CB, & to identify factors discarded Knowledge and on CBB by influencing CB donation. (n = 177) Attitude of CB use HP but they their cord *Higher knowledge were CBB employees blood. and positive attitude towards working in Convenience CBB & CBD increased the hospitals Sample likelihood of CBD CB Education *Women who used CBD were encouraged by media *44.2% who CBB and 12% who CBD were educated HP 4 Bioinformant To determine the factors International: 603 Expectant Quantitative Overall: Most study participants Analytical strategy (2018)18:395 (2014) involved in expectant parents’ Australia, NZ, Asia, parents and Survey Questionnaire had not been informed of CBB was not described decision to privately store, Europe, USA, recent parents Branched survey. options by their antenatal publicly donate or discard Canada, Middle East, (within 3 years) Specific questions asked health care professional. their infant’s cord blood. Sth America, Mexico, Sample method unsure of different respondent Source of CB banking Central America, populations. information: Obs (35%), Family Caribbean, Africa & friends (35%), ANC (14%). 45%: Information from CBB was influential in their decision. 30%: Obs significantly influential in parent decision. 77%: did not CBB as unaware of option. 62%: Obs did not mention CBB. 63%: ANC did not mention cord blood banking. 5 Jordens et al. To explore Australia, 1873 Pregnant Quantitative Overall: Most Only 1 State of (2014) awareness and NSW women (> 24 wks Self -administered women wanted Australia sampled; understanding of cord 14 public and gestation, low risk) Questionnaire: multi-choice information from not representative blood banking private antenatal Target n = 2050 format. (modified version ANC provider of national population among Australian clinics and classes in Response rate = 87% of Fernandez et al., 2003) Many respondents Awareness, not women, and maternity hospitals Purposive Sampling were aware knowledge the effect of in metropolitan of CBB. CBB was reported education of (n = 8), regional education increased planned choices (n = 4) and rural intention to on the disposal (n = 2) [included 3 CBB / CBD of cord blood. hospitals that Awareness *71% indicated facilitate CB donation] awareness of CBB; more likely to know of CBB vs CBD Source of CB banking information

*Hospital print information 21 of 5 Page (43%); print media (22%); ANC (21%), TV / radio (19%), family/relatives (17%) Decisions about CBB Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

*After receiving CBB Childbirth and Pregnancy BMC al. et basic information, proportion who indicated they would CBB or CBD increased from 30 to 68%. CBB preferences and beliefs *Only 13% had been asked about CBB or CBD prior to commencing survey. *93%: CBB and CBD information during pregnancy should be

given by ANC giver. (2018)18:395 6 Alexander et al. To determine Nigeria 302 Pregnant Quantitative Overall: Awareness of CBB and CBD (2014) awareness of CB 1 tertiary university women Structured CBD and CBB among not available in the donation and teaching hospital, ANC Convenience Questionnaires pregnant women is Country so may banking among sampling low, with media the contribute to pregnant women. main source of low awareness. information. Awareness *Only 19% aware of CB due to the absence of CBB and CBD in Nigeria. Information sources *Hospitals (30%); Media (39%), Friends (24%), Internet (7%) 7 Karagiorgou To analyse the Greece 1019 Public Quantitative Findings from parents Focused on general et al. (2014) attitudes and 5 Greek cities, citizens; 292 parents Standard only reported here population of knowledge of 2 Greek island Response rate = 100% anonymous Overall: High CBB childbearing age. Greek citizens communities. of approached multi-choice awareness level, with Did not clearly with high target population questionnaires almost half informed represent pregnant reproductive Random Sampling by a HP women or capacity (aged Knowledge and attitudes expectant couples. 18–24 years) about CBB *80% knew Awareness not about cord of CBB; 83% aware of knowledge reported. blood banking CB uses; 87% positive and therapies. about CBB Information quality *48% stated main source of CBB information, 43% of CB use information came from HP. Future attitudes *53% preferred CBD vs

47% preferred CBB 21 of 6 Page for future use. 8 Vijayalakshmi, To assess India 100 Antenatal Quantitative Overall: 95% had Minimal information (2013) antenatal mothers’ 1 regional mothers Questionnaires poor knowledge on knowledge knowledge hospital’s ANC Non-probability of CBB and collection. questions asked Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

regarding cord blood Purposive sampling *Significant association Minimal analysis Childbirth and Pregnancy BMC al. et collection and storage. between knowledge of findings presented To find an association scores and demographics Survey tool between knowledge (live birth, abortion, not validated and demographics on death, place of residence, cord blood collection type of family and and storage. membership to any organization) was found *Age, religion, gravida, para, education, occupation, income, newspaper and magazine subscription showed

no correlation with (2018)18:395 knowledge score 9 Meissner-Roloff To assess the extent South Africa 217 Mothers Mixed methods Overall: Study revealed Centre specialized & Pepper (2013) of public support 1 urban university Convenience Qualitative positive support for a in high risk for the establishment hospital, ANC sampling Interview and education public CB bank pregnancies; participants of a public cord Quantitative Anonymous in South Africa may have had blood bank. Questionnaires Willingness to better access to, Survey tools validated donate placenta and received more, and CB *80% supported information than placental donation, while rest of population 2.5% unwilling attending other clinics to donate placenta would do CBD *78% supported a public bank; 78% willing to have HIV testing for CBD process Knowledge of CB stem cells *70% unaware of stem cells prior to education session; 94% opinion that stem cells could treat blood disorders Influence of Age *Younger women more willing to donate placentas than older women (84% v 77%), more likely support CBD (92% v 82%) 10 Padmavathi To assess stem India 30 Antenatal Qualitative Overall: Results Unclear of education (2013) cell and CB banking 1 district maternity mothers Structured interviews suggest a structured content in teaching knowledge among hospital, ANC Purposive pre and post education teaching program session and how antenatal mothers sampling Post education interviews was effective and knowledge was assessed before and after a attended 7 days increased ANC Unclear if same

structured teaching following education mothers’ knowledge interview questions 21 of 7 Page program. on stem cells and CB. used pre and To assess the Pre-test Knowledge *57% had post education. effectiveness of poor knowledge; 43% structured teaching had average knowledge. Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

program on cord blood Post-test knowledge *70% Childbirth and Pregnancy BMC al. et banking and stem cell had good knowledge; 30% knowledge among had average knowledge. antenatal mothers. *Mean post-test knowledge higher (21.9%) then pre-test knowledge (10.2%). 11 Screnci et al. To explore knowledge Italy 239 pregnant Quantitative Findings reported Sample from one (2012) about CB stem cells, and University of women before CB Anonymous for pregnant women Institution only so preferences for donation Rome, ANC education given Questionnaires only. Overall: Large may not be generalised or private banking and Surveys distributed support for CBD Survey tool the motivation behind n = 300 suggests CBB is not not validated the decision. Response rate = 80% an obstacle to [298 female blood donors] expansion of Convenience CBD. HP and Sampling institutions should (2018)18:395 100 mothers provide CBB who had donated information. CB (for verification Knowledge of CB of donation *93% general knowledge; motivation) 42% probability of clinical use; 31% therapeutic uses; 58% difference CBD Vs CBB; 71% donation criteria CBD awareness *95% aware of CBD Information source *42% Obs; 25% internet CB choice (n = 215) *61% would CBD, 56% had altruistic and other reasons; *7% would CBB, 73% would do so to safeguard future *32% would discard CB, logistics (28%), lack of interest (28%) 12 Shin et al. (2011) To investigate the Korea 863 pregnant Quantitative Overall: Minimal Only highly educated, knowledge of CB and 1 Maternity women attending Questionnaires level of knowledge urban women attitudes towards CB hospital antenatal classes Questionnaire was recorded. Obs who received banking among well which did not adapted and have insignificant antenatal care educated, high-potential consist of CB enhanced from role in disseminating and education donors. banking education 3 previous studies knowledge were included. component (Fernandez et al. Knowledge 57% correctly Results may not Convenience 2003,Perlow et al. answered CB be generalized. sampling Surveys 2006, Fox et al. 2007) current use Survey Tool

distributed = 1430 and limitations not validated. 21 of 8 Page Response = 60.3% CB collection reason *CBD: Altruism most common reason (94%) *Safeguard for Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

future was most Childbirth and Pregnancy BMC al. et common reason for CBB (75%) *Most common reason for no CB collection was inconvenience of consent and medical questionnaire CB Donation motivation *54% of CBD were blood donors Source of information *88% received CBD

information; most (2018)18:395 common sources CBD of information was media/internet (37%) and brochures (31%). * 2% and 4% learnt about CBD and CBB respectively from Obs. *97% received CBB information; most common CBB information source was advertisements (38%) and media/internet (36%). 13 Manegold et al. To explore the attitudes Switzerland 300 Recent Swiss, Quantitative Overall: Motivation 84% of the open (2011) of donating parents Public CB bank western and eastern Standardised for private or questions were towards public and European public anonymous hybrid CB banking unanswered private CB banking. CB donors. questionnaire is low in Only donors whose Purposive Sampling 20 multi-choice this population. CB was accepted Surveys and open ended Source of for storage were distributed = 621 questions CBD information included in study Response rate = 48.3% *54% from HP May not be *22% from more than generalized to the 1 source: family, friends entire donor population and media Survey tool *34% actively sought not validated CBD information CBD vs CBB Options *2% would CBB for next infant *27% did not know of CBB *69% opted for CBD due to altruism and cost of CBB 21 of 9 Page 14 Katz et al. (2011) To explore pregnant 5 European countries: 1620 Pregnant Quantitative Overall: Study revealed Ethnic breakdown Europe women’s awareness France, Germany, Italy, women who Anonymous strong preference for CBD. was not reported. of CB stem cells and their Spain, United Kingdom. had not previously self-directed Attitudes were not an Data collection differed Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

attitude towards banking. 6 urban maternity enrolled in a CB multi-choice obstacle to CBB. across sites: German Childbirth and Pregnancy BMC al. et hospital antenatal banking program. questionnaire CB Information questionnaires conducted clinics with over France n = 318 and knowledge in antenatal classes 1000 births per annum UK n = 290 *79.4% declared notclinicsasin (Germany = 2 antenatal Germany n = 313 poor CBB knowledge. other 4 countries classes in lieu of clinic) Spain n = 323 *59.6% received CBB not available Italy n = 376 information via mass in 3 countries Purposive Sampling media and internet. at time of study *20% received (France, Italy and Spain) information from HP. Knowledge not *91.6% believed awareness reported. they should be Survey tool validated systematically informed. CB banking choices

*89% would collect CB; (2018)18:395 11% would discard CB; 77% would CBD; 12% would CBB; 12% would store in hybrid bank Choice for CBD *59% said altruism; 30% believe a duty to donate *24% would change birth hospital in order to be able to CBD Choice for CBB *12% would CBB; 51% of these women would do so due to possible future medical research therapies *16% would do so for insurance reasons 15 Suen et al. To assess knowledge Hong Kong 1866 Pregnant Quantitative Overall: Study revealed Sampling limited to (2011) of private cord blood 2 large public maternity units women accessing Cross-sectional inadequate knowledge public patients banking among antenatal clinic. self-administered on CBB and use. who did not pregnant women Surveys distributed = 2000 questionnaire Understanding have the option Response rate = 93.3% Survey validated *78.2% reported no of CBB unless Convenience Sampling understanding of indicated for likelihood CBB use medical reasons. Awareness *Only 58.5% were aware

of CB use for childhood 21 of 10 Page leukemia Knowledge *20.3% knew of CB availability from public CB banks Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

Preferred source of Childbirth and Pregnancy BMC al. et CBB information *44% stated Dr.; 32% stated CBB staff *22% stated unsure who to receive information from; 7% stated N/MWs Government involvement * 89% wanted more promotion and education on CBB 16 Salvaterra et al. To analyze knowledge, Italy Pregnant women, Mixed methods Findings reported from Included only those (2010) comprehension, opinions, Hospital, community future parents and using participatory pregnant women, future in an urban setting attitudes and choices & academic donors (n = 30) approach with parents and donor and didn’t include related to cord blood sector participation 32 antenatal establishment of perspectives: any minority groups. (2018)18:395 donation of pregnant health care providers a taskforce and Overall: Few knowledge women, future parents, consisting of: 10 public multidisciplinary *CBD considered a gift questions; most donors, midwives, community midwives round table of moral and social value; opinion based. obstetricians/ gynaecologists. 12 hospital midwives Focus groups; Participants would CBD for Small sample To compare preferences 10 obstetricians (max. n = 10 altruistic purposes. sizes allowed for of public versus private (public and private) participants, led by *CBB was associated with limited between banking. Multiple sampling 2 psychologists) egoism and fraud. group comparisons methods Self -administered *100% wanted more Researchers developed questionnaires at information and clear own assessment tool completion of procedures on CBB. Knowledge not reported focus groups (n = 20) *100% stated HP should be educated on CBB/CBD and inform future parents during pregnancy *70% (14/20) reported poor knowledge of CBD 17 Rucinski et al. To explore the knowledge, United States of America 41 Hispanic and Qualitative Overall: Most not aware of, Very specific (2010) attitudes, beliefs and 1 Community Health non-Hispanic 5 Focus groups: what it involved, or the inclusion criteria practices regarding Centre and 1 Community pregnant black 1 Hispanic (English) n =5 value of, CBD for treatment so results could cord blood donation Hospital in Chicago, Illinois women, or who 1 Hispanic (Spanish) n =9 and research. Participants not be generalized among Hispanic and had given birth 3 non-Hispanic n = 8/9/10 believed that Drs provide to the wider population. non-Hispanic black women. in the last 12 months, CBD information > 18 yrs., had Initial analysis did not reveal received antenatal strong ethnic difference in care by the 2nd knowledge or attitudes trimester; did not towards CBD. have any religious Knowledge/Awareness objections to donation. *Participants who reported Purposive sampling. awareness of saving CB, was in reference to CBB not CBD. *Participants reported ae1 f21 of 11 Page confusion between CBD and CBB options. Information needs and sources *Those who had birthed Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

expressed concern that Childbirth and Pregnancy BMC al. et they had’t been informed by HP on CBD option *Many wanted CBD info from their Dr. due to trust/respect in Dr. being source of factual information and perceived ability to answer questions on topic. *Some parents reported Dr. indifference on topic and Dr. failure to spend time providing health related answers to questions which

reduced faith that Drs (2018)18:395 were reliable source of information. 18 Palten & To evaluate the correlation Germany 300 Pregnant women Quantitative Overall: Women were Language interpreted Dudenhausen between German-speaking (Perlow, 2006) over the age of 18 Multi-choice response poorly educated about tool used by (2010) women’s knowledge of cord 1 obstetric hospital years in their 3rd trimester Questionnaire CB storage usefulness, Fox et al. (2007), blood banking and their level in Berlin, 3 ANC Surveys distributed = 313 costs and methods. although cultural of education. Response rate = 96% Education and health system Quota Sampling: *35% well educated differences make to gain comparative (University degree). comparisons of number to Fox et al. *Women with findings difficult. (2007) study higher education Awareness not level had read knowledge reported. more CBB information Knowledge *50–65% were unaware of CB treatable illnesses Source of CB information *74%: reading material and commercials. *59%: material by private CBB. *26%: public CBD banks. CB discussion with obstetrician *5% discussed it with Obs; 1% had it raised by Obs 19 Dinc & Sahin To determine pregnant Turkey 334 Pregnant women Qualitative Overall: Women with a Select sample (2009) women’s knowledge and 2 Antenatal clinics: accessing antenatal Exploratory descriptive higher education had of women in attitudes towards stem cells 1 in a University clinic in Instanbul. study of Interviews: higher levels of knowledge 2 antenatal clinics in ae1 f21 of 12 Page and cord blood banking Medical Centre, Convenience Sampling yes/no and open about CB and stem cells. 1 location so in Instanbul. 1 in a Family ended questions Most had a lack of may not be Planning Centre. knowledge on the topics generalized to and wanted more the rest of information from HP. the population. Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

Knowledge Awareness not Childbirth and Pregnancy BMC al. et *Only 26.9% knowledge reported. aware of CB and stem cells. Source of CB information *72% stated media; 28% stated Obs Preferred source of information *79% stated Obs; 21% stated N/MW Main reasons for CBB

*48.9% stated (2018)18:395 possible future need *22% it is beneficial; 10% future regret *8% insurance for child Main reasons against CBB *68.7% not necessary; 21% limited information 20 Fox et al. To evaluate patient United States 325 pregnant women Quantitative Overall: Women Survey conducted (2007) understanding of of America Quota sampling Anonymous had very poor in early pregnancy. cord blood banking. 1 large Obstetric Surveys distributed =724 multi-choice understanding of CB Only 45% of Hospital, New York Response rate = 44.9% questionnaire uses and banking. surveys completed with access to public Education status so may indicate and private CB 94% completed a bias of results. banking, ANC undergraduate degree Study did not 58% completed post examine the extent graduate degree. of the women’s Awareness knowledge of CBB. *54.4% unaware of medical conditions treatable with CB. Main CB Information source *86.5%: private CBB literature *29.2%: Public CBD banks literature *36.9%: Discussion with Obs though not stated who initiated the conversation.

Reasons for 21 of 13 Page private CBB *83%: protect infant in future 21 Perlow (2006) To determine patients’ United States 425 Pregnant women Quantitative Overall: Patients Addressed private knowledge of cord of America attending for antenatal Convenience Sampling poorly informed CBB only. Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

blood banking. 1 Obstetric Medical consultation, or ultrasound. 2. part q about CBB Conducted in one Childbirth and Pregnancy BMC al. et Centre Convenience Sampling uestionnaire: (74%, 315/425). location only so Phoenix, Arizona. 1. Awareness Few receive may not be 157 (37%) unaware CB education representative of of CB banking. from HP. Lack the general population. Completed part 1 only. of knowledge and Lack of cultural 2. Knowledge expense CBB barriers. diversity, small 268 (63%) completed Awareness of CBB numbers of Native part 1&2. *63% were aware. and African Americans Remainder excluded in the survey. from part 2 of study. Last two questions *Women with lower of the survey education less likely to were not completed be aware than women by all participants.

with a University degree (2018)18:395 (22% v 78%). * Women under age 25 less likely to be aware (53% v 68%). *Ethnic women had less awareness then Caucasian women. Knowledge of CBB *74% stated minimally informed. *3% stated extremely knowledgeable on the subject. Source of CBB information *53% informed by media; 17.5% informed by Dr.; 8.2% informed by other HP. Barriers to CBB *Cost (30%); low knowledge (31%), misinformation on who could use CB (50%). 22 Danzer et al. To evaluate the Switzerland 78 Women 6 months Quantitative Overall: A High Women from one (2003) attitudes of mothers 1 University post- partum who Survey degree of satisfaction Institution only towards cord Hospital with a donated cord blood Standardized anonymous with CBD. were surveyed. blood donation CB collection centre Purposive Sampling questionnaires Responses regarding CBD A total of 131 for therapeutic Response rate = 59.5% Multi-choice format, with 100% believed CBD were sent surveys use 6 months (Total surveys 1 open ended question. was ethical however, 40.5% did

post donation. distributed = 131) *96.1% would CBD again not respond. 21 of 14 Page *74.8% emotionally satisfied about CBD Original source of CBD information Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

*81.3% from Childbirth and Pregnancy BMC al. et their Dr.; 18.7% from media and friends. *No significant association between information source and decision to donate again. Open ended question comments *8 women supported importance of CB collection centres; 5 expressed concern for improper use,

2 expressed (2018)18:395 concern donated CB may not be available for own child. 23 Fernandez et al. To examine pregnant Canada 443 English speaking Quantitative Overall: Most women High proportion of (2003) women’s knowledge 1 Regional pregnant women Questionnaires developed were supportive of participants were and attitudes regarding Women’s Hospital attending antenatal clinic. by Authors CBD for transplantation university or CB banking, which Response rate = 68% and research. college educated. maybe used in (Total surveys Knowledge Little ethnic the development distributed = 650) *72% reported poor diversity in group. of policies and Convenience Sampling or very poor No established procedures for CBB knowledge (n = 310) public or private public and private 25% overestimated risk CB banks in CB banking? of a child the area at requiring a stem the time the study cell transplant was conducted. Preferred CB education source *66% HP; 68% Dr.; 70% ANC. CB Banking option *14% would choose CBB due to a good investment. *86% would choose to CBD due to altruism. 24 Sugarman et al. To evaluate the United States of America 170 Pregnant women Qualitative Overall: Women were satisfied Sample limited to (2002) informed consent 2 CB Collection centres in the 3rd trimester Telephone interviews with consent process (96.9%), those who had process for cord associated with a Public CB who had consented most (98.8%) would donate consented to CBD blood donation. Bank. to cord blood donation again, though did not seem at 1 public bank. Convenience Sampling to know about alternatives Understanding of ae1 f21 of 15 Page to CBD. CBD and uses Other responses to CBD process may differ in women *Only 32.9% understood they who chose not had the option not to have to CBD and CB collected. where CBB is Table 1 Overview of papers included in the review (Knowledge, awareness, attitude, information source, public donation, private banking) (Continued) Peberdy No. Author/Year Aim Country Setting Sample Inclusion Design Findings Limitations

*Only 55.3% understood the an option. Childbirth and Pregnancy BMC al. et option of CBB. Interviews were 78.8% incorrectly thought they conducted 1 month could donate CB to post -partum so a specific recipient. information previously Incorrect endorsement of CBD conveyed and *Diagnosis of genetic disease understood may of infant (92.9%) and mother have been forgotten. (88.2%) * Diagnosis of infectious disease of infant (88.2%) and mother (87.1%) *Protection for infant (48.8%)

25 Sugarman et al. To learn about United States of America 19 Pregnant women Qualitative Overall: 100% indicated Findings context (2018)18:395 (1998). pregnant women’s 3 antenatal clinics in their 2nd & Focus group discussions they lacked sufficient or specific, not able concerns regarding (1 private, 2 public) 3rd trimester substantial prior knowledge to be generalized CB collection affiliated with CB Purposive sampling of CB technology. to broader population. and banking in collection centres. Desire for more information order to establish a about collection, storage comprehensive recruitment and use of CB, especially and informed consent difference between CBB process for donation. and CBD was identified. CB education *100% believed in importance of CBB education including collection, storage and use. *Earlier the education was provided promoted a feeling of choice. *CB education should be in various formats: clinic pamphlets/posters, parenting magazines, information hotlines, television advertisements & reports, ANC. Safety of mother and infant *Important to inform women that CB collection does not alter the birth process. Reasons for CBD *Altruism was main reason *Influence of others may give cause for more likely CBD.

Key: CB Cord blood, CBB Private cord blood banking, CBD Public cord Blood Donation, Obs Obstetrician, N/MW Nurse/Midwife, Dr Physician, HP Health Professional, ANC Antenatal Class, OPD Outpatient Clinic 21 of 16 Page Peberdy et al. BMC Pregnancy and Childbirth (2018) 18:395 Page 17 of 21

Three papers reported low awareness of cord blood population had relatively low awareness relating to uses of banking and donation [13, 31, 39]. Participants who had cord blood [13, 31, 38]. heard about cord blood banking expressed considerable Nine papers reported knowledge of cord blood use confusion between public and private banking options [13, 27–30, 33, 35, 36, 46] and knowledge deficits were [31], with cord blood donation having the least aware- identified. Treatment of blood cancers was the most ness reported in North America [13, 31]. commonly known use of cord blood [13, 29, 30, 35], Thirteen studies reported on cord blood banking and do- with over 50% of participants correct in their responses nation knowledge [14, 15, 18, 27, 28, 32–34, 37, 41, 43–46], in studies by Fox and colleagues (n = 70%) [14] and Pal- with most studies assessing knowledge by participant ten and Dudenhausen (50–65%) [26]. Limited knowledge self-report, as opposed to knowledge being measured by as- was reported for other uses [13, 30, 36], including the sessment of associated facts. Ten studies identified likelihood of use of cord blood stem cells [28, 33]. Mati- parent-reported suboptimal knowledge about collection jevic and Erjavec (2016) reported 95% of participants in and storage options for cord blood [15, 18, 27, 28, 32–34, their study self-reported knowledge of cord blood treat- 37, 43, 44], and of parents being minimally informed about ments as either insufficient or basic [46]. cord blood banking and donation options [15, 28, 32–34, 37, 44, 45]. Exceptions to these low knowledge findings were re- Cord blood information ported by four studies, with more than 70% of participants Source of information of three studies reported to be knowledgeable about cord Source of cord blood banking information was investi- blood banking and donation [14, 41, 46]. Findings from gated by 16 of the reviewed papers [13–15, 20, 28, 30, 31, early postpartum women (n = 320) surveyed by Kim et al. 34–36, 39, 40, 42, 44–46]. The main sources of parent in- (2015) on their knowledge and attitudes of storage, dona- formation were hospitals; health professionals, including tion and disposal of cord blood suggested that a high level antenatal classes; media and magazines; cord blood banks; of knowledge about cord blood was associated with and family and friends. Table 2 summaries the sources of women opting for cord blood donation. information reported in the studies reviewed. Ten papers investigated parents’ attitudes towards Six authors reported health professionals and/or ante- cord blood banking and donation with samples including natal classes were the main source of information on cord pregnant women, expectant parents and new parents blood banking [14, 20, 36, 41, 42, 44], with a further two [14, 28, 29, 32, 34, 35, 41, 42, 44, 46]. Overall, the find- authors reporting these were the second most common ings from these studies indicated that parents were more sources [39, 40]. Health professionals, particularly doctors, inclined to support donation than private cord blood were identified as important informers of cord blood banking [14, 28, 32, 34, 35, 42, 45]. Key themes of parent banking options [20, 36, 42, 45]. Receiving this informa- attitudes towards donation and storage of cord blood in- tion from a health professional significantly influenced the cluded altruism, ethical practice, duty to society and in- parental decision to store cord blood [20]. surance for the baby. Only one paper reported low Four authors reported low numbers of participants regard for altruism or public benefit surrounding cord had received cord blood information from health profes- blood donation, however this may be attributed to lack sionals [15, 34, 35, 45, 46], and a further study found of awareness of cord blood donation as public cord that participants had to actively enquire in order to re- blood banking was not available at the time of this ceive information on cord blood donation [14]. study’s data collection [45]. Print and electronic (including internet) media and ad- Several papers found parents to be positive towards vertising were the main information source of cord blood cord blood banking [29, 41, 44, 45]. Reasons given for banking reported in six studies [15, 30, 34, 35, 39, 46], and private cord blood banking included insurance for their was the second most common source in two further pa- baby [44], the cord blood may be needed in the future pers [36, 40] after health professionals [36] and private and they may have future regret of not storing their cord blood banks [40]. baby’s cord blood [29]. Four studies listed cord blood banks as a source of cord blood banking information [13, 20, 30, 40], with Jordens and colleagues [36] reporting this was the main Cord blood use source for their participants. Private banking informa- Five papers reported on cord blood use awareness tion was reported as a more common source of informa- [13, 31, 38, 41, 46], with only one paper reporting high tion compared to public banks [13, 30]; one study awareness, which included participants who were already reported that almost half of their sample indicating that parents [41]. Three studies used mixed methods and information from private cord blood banks was influen- reported that considerable proportions of the parent tial in their decision to store cord blood [20]. Peberdy et al. BMC Pregnancy and Childbirth (2018) 18:395 Page 18 of 21

Six reports noted family and friends to be a source of in- blood did so because they viewed this option as an invest- formation [14, 20, 36, 39, 42, 47], though only one paper ment for future use, insurance or protection for their child stated this was their main source [20]. Three studies com- or family [28, 29, 34, 35, 44]. The desire of parents to do the bined ‘family, friends and media’ as a single information best for their children and provide for their future may influ- source category [15, 28, 32]. These studies reported similar ence their interpretation of the importance of the scientific findings with approximately 20% of participants identifying benefit on storing cord blood stems cells for future health this category as a source of cord blood banking information protection, and illustrates the emotional element frequently and an influence in their decision-making [15, 32, 38]. attached to this option. Knowledge on cord blood use among study participants Preferred source of information was mixed. Over 50% of participants in many of the studies Five papers reported on participants preferred source of could not correctly identify uses of cord blood [13, 18, 27, information on cord blood banking and donation [28, 29, 30, 33, 36, 46]. This lack of knowledge emphasises the 29, 31, 33, 40, 45]. Four studies listed antenatal health uncertainty about the source and the quality of the infor- professionals, including antenatal classes, as the most mation being provided. When knowledge was self-reported important and preferred source [29, 31, 33, 40, 45]. Only by participants, general uses for cord blood was higher than one paper reported cord blood banks as a preferred specific uses [29, 30, 36], with treatment of blood cancers source of information [33]. Table 2 displays the preferred the highest correct response reported [14, 26]. information sources reported by participants of studies Awareness among parents of the value of cord blood and included in this review. cord blood uses was found to be less than knowledge levels of cord blood value and use. We identified that the provision Discussion of information by health professionals greatly influenced Cord blood banking and donation has been an option awareness of the value of cord blood and its’ potential uses. for parents for the past quarter century, yet an under- This finding again emphasises the need for information to standing of knowledge and awareness of these options, be provided as part of routine antenatal care. and consistency of information provided to parents, re- In this integrative review, we found that there was in- mains low. This is the first integrative review to explore consistency in information provided to parents about parents’ knowledge, awareness and attitudes towards cord blood banking and cord blood use. This inconsist- cord blood banking and donation, and parent sources, ency created awareness and knowledge deficits and argu- and preferred source, of information on this topic. ably prevents parents from making informed choices. This integrative review identified parents’ knowledge This is an important finding; in Australia, the Health of cord banking and/or donation as generally low [18, and Safety commission have identified involving con- 27, 28, 32–34, 37, 44–46]. Higher knowledge levels were sumers in health care choices is associated with better identified where participants had previously donated client experience and promotes client centered care [48]. cord blood and where participants had been provided Information sources for parents on cord blood was found with information on these options by their antenatal to be varied, fragmented and inconsistent [14, 20, 35, 40]. health care provider or in antenatal classes [14, 41, 44]. This inconsistency of information is concerning because for This finding highlighted the importance of providing parents to make informed choices about cord blood bank- parents with this information as part of routine antenatal ing or donation they need appropriate, relevant, objective education. Overall, awareness of cord blood banking op- information that is accurate, valid, regulated and based on tions was found to be higher than knowledge in this in- thelatestevidenceinavarietyofconsumer-friendlyformats tegrative review [15, 41, 47]. Like knowledge findings, through trustworthy sources [49]. this may be attributed to the availability of information Health professions were identified as the preferred provided at birthing facilities, and the level of education source of information on cord blood banking for parents of participants [15, 40, 41]. [28, 29, 31, 33, 40, 45]. The views of clients are among Positive attitudes towards cord blood donation among par- many factors that influence change to health services ents were found, with the option considered to be an ethical [50] and it is imperative that information on cord blood [42] and altruistic choice for parents [14, 28, 34, 35, 41]. This banking and donation is considered as part of routine could be indicative that cord blood donation has a moral as- antenatal education for parents. sociation, and this finding may be important when health professionals discuss this option with parents as they may Strengths and limitations of this study feel pressure or an obligation to choose this option. Positive The integrative approach chosen for this review of par- attitudes towards private cord blood banking were also ent knowledge and awareness of cord blood banking, do- found, with only one study reporting negative findings [32]. nation and cord blood banking, including sources and Participants who chose to privately store their infant’scord preferred sources of information, allowed for the Peberdy et al. BMC Pregnancy and Childbirth (2018) 18:395 Page 19 of 21

inclusion of a diverse range of qualitative, quantitative blood use and how this impacts on the information that and mixed methods studies with participant samples they provide to expectant parents in their care. The option from nations representing most world continents. Des- of cord blood banking and donation has been available to pite the literature review being extensive, inclusive of parents for over 25 years so it is timely to investigate where published studies meeting eligibility criteria since cord the gaps in health professionals’ knowledge lie. blood banking became available in 1991, this integrative review was limited to studies published in the English Practice language only. Different terminology and sampling de- Information on cord blood banking and cord blood use is scriptions (pregnant women and / or parent / couples’ not a standard element of antenatal education and this is knowledge) used across studies, and a lack of clarity and concerning because parents require this information to consistency within studies relating to study aims and make a fully informed choice of their options regarding their methods reported, limited interpretation of some study infant’s cord blood following birth. We argue that there is a results. need for health professionals to provide accurate and The papers included in this review varied significantly evidence-based information to parents. This integrative re- in sample size (n = 30 to 1873), but this may have been view has demonstrated that information provision to expect- driven by the research approach chosen [18, 31, 32, 37]. ant parents by health professionals on the topic of cord Survey tools to measure knowledge, awareness and atti- blood banking and donation is not a consistent part of ante- tudes were poorly described or not validated in some natal education. Research is needed to identify and under- studies [14, 32, 35–37, 43, 46], with only two studies stand barriers to the information provision to parents on using the same (or modified version) tool [13, 30]. cord blood banking and donation, and why this important Several papers reported on awareness, not knowledge, topic is not yet a standardised part of antenatal education. as indicated in their title or abstract [29, 30, 32, 40, 41] or on knowledge, when awareness was indicated [34]. Education The findings of some studies were context specific and Health professionals are the parent preferred source of may not be generalised [14, 18, 31, 35–37], or partici- cord blood banking information. It is vital that health pants did not have access to both cord blood banking professionals are educated and informed of all aspects and donation which may have influenced study findings and elements of cord blood banking to enable them to [15, 27, 28, 33, 34, 39]. provide appropriate information to parents. We argue that cord blood banking should be incorporated into Implications for practice, education and research health professional curricula and antenatal education. In this integrative review, inconsistencies, and uncertainty in knowledge and awareness that parents have regarding Conclusion cord blood use and banking options have been highlighted. Cord blood banking is complex and often poorly under- These findings are indicative of the need for expectant par- stood by parents and health professionals. This integra- ents to be informed of the cord blood banking options tive review makes an important contribution to the body available to them by their antenatal care providers and/or of knowledge in this field by identifying knowledge, at their birthing facility so that they can make an informed highlighting gaps and suggesting direction for future re- decision about what option is appropriate for their family search, practice and education in relation to cord blood circumstances. Maternity care policy and practice evolve banking and donation and cord blood use. with the emergence of new research evidence [49]; health Significant gaps in parents’ knowledge and awareness services therefore need to be responsive to client and con- of cord blood banking have been identified in this review sumer input and needs [48] and involve clients in health of current evidence. This is an important topic and one care and informed decision making. that requires parents to make informed and rationale choices. For this to occur, information provided needs to Research be accurate, objective valid, timely and appropriate, and Parent knowledge of cord blood banking options and cord supplied by parent preferred sources. As identified in blood use has been identified as poor. This integrative re- this integrative review, currently this is not the case. view identified that parents have a lack of knowledge about This integrative review has identified that further re- the options of cord blood banking and donation, and the search should focus on identifying the information ex- uses of cord blood. There is lack of clarity and consistency pectant parents would like to receive to assist them to in the information provided for parents on cord blood make an informed choice around cord blood banking banking, donation and cord blood use. Future research is and to identifying the barriers to health professionals needed to explore health professionals’ knowledge of, and providing this evidence-based information on cord blood attitudes towards, cord blood banking, donation and cord use and banking options. Peberdy et al. BMC Pregnancy and Childbirth (2018) 18:395 Page 20 of 21

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Ongoing ethical issues concerning Availability of data and materials authorship in biomedical journals: an integrative review. Int J – Not applicable to this integrative review of published studies. Nanomedicine. 2015;10:4837 46. 17. Whittmore R, Knafi K. The integrative review: updated methodology. J Adv Nurs. 2005;52(5):546–53. Authors’ contributions 18. Sugarman J, Cogswell B, Olson J. Pregnant Women's Perceptives on All authors conceptualized the review and selected the review methodology. umbilical cord blood banking. J Women's Health. 1998;7(6):747–57. LP conducted the literature search, identified articles for inclusion and analysis, and drafted the initial manuscript. JY, DM and LK checked the 19. CASP: Making sense of evidence. search strategy, reviewed included articles, and contributed to the 20. Bioinformant Worldwide LLC. Cord blood banking survey 600+ recent and – contributed to critical revisions of the manuscript. 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