Health Care Professionals’ Knowledge and Attitudes Regarding Umbilical Cord Blood Banking in Saudi Arabia

Raghad Bandar Alharbi¹, Khalid Talal Aboalshamat^2*, Muneera Abdullah Qattan³, Rsal Rabea Alrefaei³, Renad Turki Alhazmi³, Roudin Hussain Alhasawi³, Raghad Obaidallah Al-Masoudi³, Aseel Muneer Alahmadi³, Abrar Ahmed Alghamdi³ and Ashjan Yousef Bamahfouz⁴

^*Correspondence: Khalid Talal Aboalshamat, Dental Public Health Division, Preventive Dentistry Department, Faculty of Dentistry, Umm Al-Qura University, Makkah, Saudi Arabia, Email:

Author info »

Introduction

Umbilical cord blood (UCB) banking has received much attention over the past several decades. They can be thought of as “life banks” due to their role as a backup source for maintaining human health [1,2] by, immediately after the birth of a baby [3], collecting and storing UCB. UCB is the blood present in the umbilical cord and placenta after childbirth that contains a substantial number of stem cells [4,5]. In the past, UCB was treated as medical waste [6], but recently, scientists discovered that UCB is a rich source of unique stem cells, and it is now considered a promising treatment option [7].

There are generally two types of stem cells: embryonic stem (ES) cells and non-ES cells. Non-ES cells are found in several tissues, including UCB, bone marrow, skin, and products of pregnancy, such as the amniotic fluid and placenta [8]. The preference for UCB stem cells over other sources is expanding in the medical field due to the fact that UCB can be collected through a non-invasive procedure, without risk to the donor [9]. UCB is viewed as a primary stem cell source. Now, UCB is widely accepted as an unlimited alternative source to bone marrow and the peripheral blood of hematopoietic stem cells (HSCs) [8].

Clinical applications of UCB transplantation (UCBT) date back to 1988, when the procedure was used for a 5-year-old boy suffering from Fanconi’s anemia [10,11]. Since then, it has been widely used in transplants to treat a wide variety of life-threating diseases, including acute and chronic leukemia, aplastic anemia, Fanconi anemia, myelodysplastic syndromes, β thalassemia, bone marrow failures, metabolic diseases, and immune deficiencies [12–16].

The first public UCB bank was established in New York in 1993 [17]. There are two types of UCB banks. In private UCB banks, UCB is stored at a certain cost, and the collected UCB is only available to the child or the child’s family for potential personal (autologous) use. In contrast, public UCB banks store UCB at no charge, and the UCB is available to anyone who needs a transplant (allogenic transplant) [18]. Currently, there are more than 100 UCB banks around the world [19]. In Saudi Arabia, there are currently two public UCB banks; there are no private banks because they are prohibited by law [6].

Several studies have been conducted internationally exploring knowledge about UCB banking, its usefulness, and the private and public banks alternatives among pregnant women and healthcare professionals. These studies have revealed that pregnant women have poor knowledge about the donation of UCB and the differences between public and private banks [20]. In a recently published integrative review, nine papers covering studies of health care professionals’ knowledge, attitudes, and practices pertaining to UCB donation and banking were retrieved, and the authors concluded that there was an overall lack of knowledge about UCB bank options [21].

Some previous studies aimed to identify the barriers to pregnant women gaining knowledge to form opinions and attitudes about UCB banking, and researchers have determined that women are not well-informed about this topic [22–24]. Only a few health care professionals consistently provide UCB banking education for pregnant women, despite most patients identifying health care professionals as the key source of information on the topic. So, the main barriers to UCB banking are a lack of knowledge and the high cost involved [1,25].

A study conducted in Brazil in 2021 among pregnant women found that 61% were aware of UCB banking, but 86.9% knew little or very little about it [26]. Also in 2021, a study of Polish women showed that 84.6% of the Polish pregnant women were aware of the possibility of UCB banking. Among these women, social media was considered the main source of information (47.5%) about UCB banking. However, 86.8% of the participants indicated that their doctor was their preferred source of reliable information, which is likely why 61.8% of the women assessed their level of knowledge about UCB banking to be insufficient [27].

Moreover, an interesting qualitative study conducted in Australia in 2020 among public and private maternity health professionals (midwives and obstetricians) revealed that informing parents about or discussing UCB banking with them was not a priority or part of their routine practices [28].

In Saudi Arabia, as in other countries, knowledge and attitudes about UCB banking among pregnant women appear to be minimal. Two survey-based studies showed that about half of the subjects were unaware of UCB banking and its uses; however, more than half of the women had a good attitude toward UCB donation [6,29].

Health care professionals, nurses, and midwives are supposed to inform pregnant women about this topic during prenatal consultations, because pregnant women need to be aware of the options that exist for their infant’s cord blood in order to make a clear decision [30] before giving birth. In line with this premise, the aim of the present study was to evaluate the knowledge and attitudes about UCB banking among health care practitioners in Saudi Arabia.

Materials and Methods

This cross-sectional study investigated the level of knowledge and attitudes about UCB banking among health care practitioners in Saudi Arabia. Participants were recruited using a convenience sampling method. The study’s inclusion criteria included students and practitioners in various health specialties (medicine, dentistry, pharmacy, nursing, and medical sciences) in Saudi Arabia. Participants who did not agree to the study’s informed consent or who did not fulfill the participant criteria were excluded. Data were collected from July to September 2021. All participants agreed to the informed consent before completing the study questionnaire, and all data are kept anonymous. Participants voluntarily completed an online self-administered questionnaire in English. The questionnaire was distributed via a link shared with health care professional groups on social media platforms (Twitter, WhatsApp, and Telegram). Completion of the questionnaire took from 3 to 5 minutes.

The questionnaire was composed of three sections. Section one included nine demographic questions asking about gender, age, education level, specialty, years of practice, whether in a private or governmental college, region of residence, and nationality. It also contained two questions that assessed respondents’ general awareness of UCB banking. Section two consisted of 12 multiple-choice questions that assessed knowledge about UCB banking, with one correct answer worth one point for each question. The total knowledge score, ranging from zero to 12, was the sum of correct answers in this section. Section three had four multiple-choice questions to assess attitudes toward UCB banking. The questionnaire was based on an earlier study, with minor changes [6]. SPSS v.25 (IBM, Inc., Armonk, NY, USA) and Excel software were used to analyze the data. Descriptive statistics, including the mean, standard deviation, count, and percentage, are used to present the data. Statistical significance was set at a p-value of 0.05. Data were analyzed with chisquare, linear regression, t-test, and ANOVA.

Ethical approval was secured from the Institutional Review Board of Umm al- Qura University with number of HAPO- 02-K-012-2021-08-728. Before answering the study questionnaire, all the participants were asked to agree the study consent.

Results

A total of 384 participants completed the questionnaire, with a mean age of 24.57 years and a standard deviation (SD) of 8.39 years. The majority of the respondents were female (n=298, 77.6%), and there were 86 males (22.4%). Among those participants, 369 (96.1%) were Saudi, and only 15 (3.9%) were non-Saudi. The qualifications of the participants were 272 (70.8%) students, 37 (9.6%) interns, 33 (8.9%) GPs/residents, and 42 (10.9%) specialists/ consultants. For the place where they studied, 354 of the respondents had graduated or were still studying in governmental colleges, and only 30 (7.8%) were from a private college. Finally, the median number of years of experience was zero, with a range of 0 to 35 years. The demographic results are presented in detail in Table 1.

Table 1: Participant demographic variables (n=384).

Table 2: Knowledge about UCB banking.

Table 3:The relationship between total knowledge scores and participants’ demographic data.

Table 4: Attitudes about UCB banking.

Discussion

The aim of the present study was to assess Saudi Arabian health care professionals’ knowledge and attitudes about UCB banking. However, 58% of the respondents had not heard of UCB banking previously, and 60% did not know what it is. Specialists/consultants had significantly higher scores than students, interns, and general practitioners. Conversely, the total knowledge score was not significantly different in terms of gender, region of residence, nationality, specialty, and place of study/work. The main sources of information about UBC banking for the participants were medical personnel or social media. Most of the participants had good attitudes about storing and sharing cord blood for research in UBC banks.

In this study, 60% of the participants did not know the correct description of UCB banking. Similar findings were reported by Hatzistilli and colleagues from Greece in a survey of health care professionals [31], where 85% had low levels of knowledge about cord blood and UCB banking. This might indicate that UCB banking is not marketed well, even among health care professionals; such a revolutionary area requires that health care professionals be educated on the topic, given that they are the primary source of medical knowledge for the public.

The bivariate analysis from the present study is consistent with the findings from the previous study in Greece [31] in finding no statistically significant relationships between most of the demographic characteristics and the percentage of correct responses. However, in this study, specialists/consultants exhibited better knowledge on the topic than students, interns, or general practitioners, while in the Greek study [31], a statistically significant relationship was found between correct answers and the professional role, with physicians correctly answering the most questions, followed by blood nurses, midwives, and last, non-specialist nurses. This could be related to higher rates of attendance at continuing education programs, scientific workshops, and conferences, which differ from country to country.

Few studies have examined the knowledge, attitudes, and practices of health professionals regarding UCB banking and donation. When the participants in the present study were asked if there are any health risks associated with UCB collection, only 30% of the health care professionals answered correctly. Conversely, when the same question was asked in an earlier study conducted in Saudi Arabia among pregnant women, 50% answered correctly [6]. Because the same question was asked, it was supposed that health care professionals would exhibit higher levels of knowledge than pregnant women. Thus, the results are unexpected and might indicate that health care professionals are deficient in knowledge about this area in comparison to the public. The reasons for this unexpected result might be due to pregnant women being more interested because of the personal matter of their pregnancy than health care professionals, who received the same information as a part of their curricula.

While expectant parents see health care professionals as the key source of information about UCB banking options [32–38], they unfortunately receive most of their information from untrusted sources, such as the media, family, and friends, and these sources are often based on unscientific information that is misleading or can cause panic [23,39]. Specifically, health care professionals were the source of information for 10% of public respondents in the Saudi [6] study, 6.7% in France, 18.9% in the United Kingdom, 21.5% in Italy, 22.9% in Spain, and 24.8% in Germany [24]. Conversely, in Switzerland, 60% of the participants received information from their health care professionals [40]. One of the explanations for this discrepancy is that there is a clear shortage of evidence-based guidelines regarding UCB banking to assist health care professionals in providing accurate information to their patients.

The present study highlighted the necessity of educating health care providers with accurate and detailed information about UCB banking and the currently available therapeutic options because they play an active role in educating expectant parents, who require accurate and unbiased information to support their decisionmaking about their care from a trusted source with no financial interest. Interestingly, most studies are in agreement about the importance of educating health care professionals about UCB banking so that they can confidently discuss the topic with their patients [41-44].

Further research into the topic using valid and reliable tools is required to gain a thorough understanding of health care professionals’ knowledge and practices regarding UCB banking. The use of these research findings will contribute to the development of future educational curricula, professional educational campaigns, and training programs for health care professionals and medical students about UCB collection, storage, and uses. That, in turn, impacts the professionals’ ability to effectively perform their role regarding the precious resource of stem cells.

This study had a relatively large sample size and a diversity of cities. Some of the limitations encountered were the convenience sampling technique, which may not be representative of the population. Therefore, the results should be interpreted carefully. In addition, this was a short-term study, and thus there is no longterm follow-up to analyze whether enhanced knowledge about UCB donation might lead to an increase in donation rates. In addition, the questionnaire was a simple, self-reported format, and more points are needed for a better investigation.

Conclusion

More than half of the participating health care practitioners in Saudi Arabia had not heard and did not know about UBC banking, indicating that health care practitioners’ knowledge levels were poor. Knowledge was significantly better with increased age and among specialists/ consultants. The main sources of information about UBC banking were medical personnel or social media. A majority of the participants had good attitudes about storing and sharing cord blood in UBC banks for future research. It is recommended that educational stakeholders and continuing education bodies boost health care practitioners’ knowledge about UCB banking and the currently available therapeutic options, given that health care practitioners are the primary source of trusted health information for the public.

Acknowledgements

Authors want to thank all the participants for answering the study questionnaires.

List of Abbreviations

UCB: Umbilical cord blood.

References

1. Lu H, Chen Y, Lan Q, et al. Factors that influence a mother’s willingness to preserve umbilical cord blood: A survey of 5120 Chinese mothers. PLoS One 2015; 10:e0144001.

Indexed at, Google Scholar, Cross Ref

2. Palten PE, Dudenhausen JW. A great lack of knowledge regarding umbilical cord blood banking among pregnant women in Berlin, Germany. J Perinat Med 2010; 38:651–657.

Indexed at, Google Scholar, Cross Ref

3. Armstrong AE, Fonstad R, Spellman S, et al. Current knowledge and practice of pediatric providers in umbilical cord blood banking. Clin Pediatr 2018; 57:161–167.

Indexed at, Google Scholar, Cross Ref

4. Rocha V, Gluckman E. Clinical use of umbilical cord blood hematopoietic stem cells. Biol Blood Marrow Transplant 2006; 12:34–41.

Indexed at, Google Scholar, Cross Ref

5. Ali H, Al-Mulla F. Defining umbilical cord blood stem cells. Stem Cell Discovery 2012; 2:15–23.

Indexed at, Google Scholar, Cross Ref

6. Jawdat D, AlTwijri S, AlSemari H, et al. Public awareness on cord blood banking in Saudi Arabia. Stem Cells Int 2018; 8037965.

Indexed at, Google Scholar, Cross Ref

7. Broxmeyer HE, Douglas GW, Hangoc G, et al. Human umbilical cord blood as a potential source of transplantable hematopoietic stem/progenitor cells. Proc Natl Acad Sci 1989; 86:3828–32.

Indexed at, Google Scholar, Cross Ref

8. Zhong XY, Zhang B, Asadollahi R, et al. Umbilical cord blood stem cells: What to expect. Ann N Y Acad Sci 2010; 1205:17–22.

Indexed at, Google Scholar, Cross Ref

9. Welte K, Foeken L, Gluckman E, et al. International exchange of cord blood units: The registry aspects. Bone Marrow Transplant 2010; 45:825–31.

Indexed at, Google Scholar, Cross Ref

10. Karagiorgou LZ, Pantazopoulou M-NP, Mainas NC, et al. Knowledge about umbilical cord blood banking among Greek citizens. Blood Transfus 2014; 12:s353.

Indexed at, Google Scholar, Cross Ref

11. Gluckman E. History of cord blood transplantation. Bone Marrow Transplant 2009; 44:621–626.

Indexed at, Google Scholar, Cross Ref

12. Kuwatsuka Y, Kanda J, Yamazaki H, et al. A comparison of outcomes for cord blood transplantation and unrelated bone marrow transplantation in adult aplastic anemia. Biol Blood Marrow Transplant 2016; 22:1836–1843.

Indexed at, Google Scholar, Cross Ref

13. Laughlin MJ, Eapen M, Rubinstein P, et al. Outcomes after transplantation of cord blood or bone marrow from unrelated donors in adults with leukemia. N Engl J Med 2004; 351:2265–2275.

Indexed at, Google Scholar, Cross Ref

14. Gluckman E, Rocha V, Ionescu I, et al. Results of unrelated cord blood transplant in fanconi anemia patients: Risk factor analysis for engraftment and survival. Biol Blood Marrow Transplant 2007; 13:1073–1082.

Indexed at, Google Scholar, Cross Ref

15. Rocha V, Cornish J, Sievers EL, et al. Comparison of outcomes of unrelated bone marrow and umbilical cord blood transplants in children with acute leukemia. Blood 2001; 97:2962–2971.

Indexed at, Google Scholar, Cross Ref

16. Tsuji Y, Imai K, Kajiwara M, et al. Hematopoietic stem cell transplantation for 30 patients with primary immunodeficiency diseases: 20 years experience of a single team. Bone Marrow Transplant 2006; 37:469–77.

Indexed at, Google Scholar, Cross Ref

17. Stanevsky A, Goldstein G, Nagler A. Umbilical cord blood transplantation: Pros, cons and beyond. Blood Rev 2009; 23:199–204.

Indexed at, Google Scholar, Cross Ref

18. Pandey D, Kaur S, Kamath A. Banking umbilical cord blood (UCB) stem cells: Awareness, attitude and expectations of potential donors from one of the largest potential repository (India). PLoS one: 2016; 11:e0155782.

Indexed at, Google Scholar, Cross Ref

19. Rajendran S, Kirubhakaran A, Alaudheen R, et al. Stem cell banking: Are South Indian mothers aware? Cell Tissue Bank 2018; 19:791–8.

Indexed at, Google Scholar, Cross Ref

20. Grano C, Scafa V, Zucaro E, et al. Knowledge and sources of information on umbilical cord blood donation in pregnant women. Cell Tissue Bank 2020; 21:279–287.

Indexed at, Google Scholar, Cross Ref

21. Peberdy L, Young J, Kearney L. Health care professionals’ knowledge, attitudes and practices relating to umbilical cord blood banking and donation: An integrative review. BMC Pregnancy Childbirth 2006; 16:1–19.

Indexed at, Google Scholar, Cross Ref

22. Dinç H, Sahin NH. Pregnant women’s knowledge and attitudes about stem cells and cord blood banking. Int Nurs Rev 2009; 56:250–256.

Indexed at, Google Scholar, Cross Ref

23. Fernandez CV, Gordon K, Van den Hof M, et al. Knowledge and attitudes of pregnant women with regard to collection, testing and banking of cord blood stem cells. CMAJ 2003; 168:695–698.

Indexed at, Google Scholar

24. Katz G, Mills A, Garcia J, et al. Banking cord blood stem cells: Attitude and knowledge of pregnant women in five European countries. Transfusion 2011; 51:578–86.

Indexed at, Google Scholar, Cross Ref

25. Perlow JH. Patients’ knowledge of umbilical cord blood banking. J Reprod Med 2006; 51:642–648.

Indexed at, Google Scholar

26. Zomer HD, Gonçalves AJG, Andrade J, et al. Lack of information about umbilical cord blood banking leads to decreased donation rates among Brazilian pregnant women. Cell Tissue Bank 2021; 22:597-607.

Indexed at,  Google Scholar, Cross Ref

27. Pisula A, Sienicka A, Stachyra K, et al. Women’s attitude towards umbilical cord blood banking in Poland. Cell Tissue Banking 2021; 22:587-596.

Indexed at, Google Scholar, Cross Ref

28. Peberdy L, Young J, Massey D, et al. Maternity health professionals’ perspectives of cord clamp timing, cord blood banking and cord blood donation: A qualitative study. BMC Pregnancy Childbirth 2020; 20:1–10.

Indexed at, Google Scholar, Cross Ref

29. Habib F, ALFozan H, Prince J, et al. Evaluation of knowledge and attitude of pregnant Saudi women toward cord blood donation. J Health Med Nurs 2017; 44:53–62.

Indexed at, Google Scholar

30. Yildirim G, Sahin NH. Kök Hücre Nakli ve Hemsirelik Yaklasimi. Florence Nightingale J Nurs 2014; 15:188–194.

Indexed at, Google Scholar, Cross Ref

31. Hatzistilli H, Zissimopoulou O, Galanis P, et al. Health professionals’ knowledge and attitude towards the umbilical cord blood donation in Greece. Hippokratia 2014; 18:110–115.

Indexed at, Google Scholar

32. Herlihy MM, Delpapa EH. Obstetricians and their role in cord blood banking: Promoting a public model. Obstet Gynecol 2013; 121:851–5.

Indexed at, Google Scholar, Cross Ref

33. Waller-Wise R. Umbilical cord blood: Information for childbirth educators. J Perinat Educ 2011; 20:54–60.

Indexed at, Google Scholar, Cross Ref

34. Kharaboyan L, Knoppers BM, Avard D, et al. Understanding umbilical cord blood banking: What women need to know before deciding. Womens Health Issues 2007; 17:277–80.

Indexed at, Google Scholar, Cross Ref

35. Martin PL, Kurtzberg J, Hesse B. Umbilical cord blood: A guide for primary care physicians. Am Fam Phys 2011; 84:661–666.

Indexed at, Google Scholar

36. Ikuta LM. Human umbilical cord blood transplantation: What nurses need to know. Adv Crit Care 2008; 19:264–267.

Indexed at, Google Scholar, Cross Ref

37. Abdullah Y. Cord blood banking: What nurses and healthcare providers should know. MCN Am J Matern Child Nurs 2011; 36:344–350.

Indexed at, Google Scholar, Cross Ref

38. Percer B. Umbilical cord blood banking: Helping parents make informed choices. Nurs Womens Health 2009; 13:216–223.

Indexed at, Google Scholar, Cross Ref

39. Screnci M, Murgi E, Pirrè G, et al. Donating umbilical cord blood to a public bank or storing it in a private bank: Knowledge and preference of blood donors and of pregnant women. Blood Transfus 2012; 10:331–337.

Indexed at, Google Scholar, Cross Ref

40. Danzer E, Holzgreve W, Troeger C, et al. Attitudes of SWISS mothers toward unrelated umbilical cord blood banking 6 months after donation. Transfusion 2003; 43:604–608.

Indexed at, Google Scholar, Cross Ref

41. Mohammed HS, el Sayed HA. Knowledge and attitude of maternity nurses regarding cord blood collection and stem cells: An educational intervention. Journal of Nursing Education and Practice 2015; 5:58.

Indexed at, Google Scholar, Cross Ref

42. Moustafa MF, Youness EM. Nurses knowledge about umbilical cord blood banking and it’s barriers. J Nurs Health Sci 2015; 4s:44–53.

Indexed at, Google Scholar

43. Roh EY, Shin S, Kim BJ, et al. Roles of obstetricians in quality management of cord blood collection and informing potential donors: a survey on obstetricians’ understanding of cord blood in Korea. Transfusion 2014; 54:3164–3172.

Indexed at, Google Scholar, Cross Ref

44. Walker T, Steckler D, Spellman S, et al. Awareness and acceptance of public cord blood banking among practicing obstetricians in the United States. Transfusion 2012; 52:787–793.

Indexed at, Google Scholar, Cross Ref