INTRODUCTION:

The human body is made up of three basic categories of cells: germ cells, somatic cells, and stem cells. Somatic cells include the bulk of the cells that make up the human adult and each of these cells in its differentiated state. Germ cells are cells that give rise to gametes, i.e., eggs and sperms.¹

Whereas stem cells are cells that can become establishes an appropriate growing environment, has the ability to multiply, can produce cell types that continue to differentiate and renew itself or ensure the continuation of its own population and can regenerate tissue with functional damage.² Stem cells have different types which include embryonic, umbilical cord blood and adult stem cells.³

Umbilical cord is the main link and vital attachment, which is always represented as blood and emotional parenthood relationship.⁴ As the newborn, is delivered, and the umbilical cord is divided, blood can be collected from the segment of cord still attached to the placenta. Stem cells retrieved from the blood in the remaining segment of the umbilical cord and placenta are known as ‘umbilical cord blood (UCB) stem cells.’ This blood which is of no use to the mother or the baby and has been treated as a medical waste for centuries is a rich source of stem cells. UCB stem cells are unique and have many promising uses for the future. The collection procedure is easy and without any risk to the donor (mother or baby). Unlike embryonic stem cells these are not ethically controversial. Unlike, other sources, these can also be transplanted even without an identical HLA match.⁵

Umbilical cord blood (UCB) collected from the umbilical cord differs from the peripheral blood in its properties. It is a rich source of hematopoietic stem cells, which have the properties of self-renewal as well as the ability to differentiate into myeloid and lymphoid cell lineages. DNA in these cells has a longer telomere length, which helps in long time hematopoiesis. The cord blood is also a rich source of mesenchymal cells, which are known to suppress the response of Graft-versus-host disease (GVHD).Human Leucocyte Antigen (HLA) matching is required to prevent rejection and other transplant related complications. With advances in cord blood transplantation, many such patients are now able to find a fully or partially HLA-matched cord blood donor. Various centers across the world are performing cord blood stem cell transplantation for a variety of genetic, hematologic, immunologic, metabolic, and oncologic disorders.⁶

Umbilical cord blood banking is the process of collecting and storing umbilical cord blood, in the immediate period after the birth of a baby. Cord blood can be collected and stored either publicly or privately. Public cord blood banks operate in all developed countries, and within most developing countries. By 2014, the international cord blood banking network comprised over 160 public cord blood banks in 36 countries, with over 731,000 umbilical cord blood units stored.⁷

Public cord blood banks collect, transport, process, test and store cord blood units which have been altruistically donated for allogeneic use, at no financial cost to the donating parents.⁸The donated cord blood unit is not reserved for the use of the donating family, who relinquish their rights of ownership of the blood to the banking facility.⁹

Private cord blood banks charge parents a fee for the collection, processing and storage of their infant’s cord blood for exclusive autologous or family use.⁷

Parents can decide if they would like to privately store their infant’s cord blood for later use, if needed, publicly donate it, and defer cord clamping to allow their infant to receive optimal volumes of cord blood at birth or to discard the remaining cord blood with the placenta after birth. 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. Parents’ knowledge and understanding of cord blood banking and donation has been reported to be low and little is known about their source of information on this topic and the quality of the information provided.¹⁰

Despite growing evidence of the therapeutic benefits of umbilical cord derived stem cells and promotion of umbilical cord blood collection for allogeneic, family directed, or autologous use in the media, surveys reveal that the majority of pregnant women (70 to 80%) lack knowledge about stem cells and cord blood banking and want more information.^11-12

While most women (80% to 90%) would prefer to receive information about cord blood banking from their health care professionals, prenatal education and counseling is only provided to a minority (15 to 30%). Consequently, many pregnant women receive information through printed material, the internet, or the media. Surveys from Canada, Europe, and the United States suggest that once informed, the majority of women would consider donating cord blood for therapeutic use. Overall, women appear to be more inclined to donate to public banks than to private or hybrid banks.^13-14

Nisha Philip and Seeta Devi. (2017) conducted a study to improve the knowledge and attitude of antenatal mother regarding umbilical cord stem cell banking at Pune. 60 antenatal were recruited by non-probability sampling technique and data are collected using semi-structured questionnaire. The findings revealed that in pretest most of the antenatal mother (75%) had average knowledge and after intervention most of the antenatal mother (65%) had good knowledge.¹⁵

There has been a significant increase in cord blood stem cell research in recent years, but very little is known. Hence, the present study was conducted to assess pregnant women's knowledge and attitude towards cord blood stem cells banking in Odisha.

MATERIALS AND METHODS:

Research Approach:

In the present study, cross-sectional survey approach was used.

Study Design:

This study was a descriptive study design

Setting:

The study was conducted at the SCB, Medical College and Hospital, Cuttack, Odisha. This is a busy hospital conducting about 35,000- 36,000 deliveries per year. The study was carried out in the Obstetrics and Gynaecology outpatient department of SCB, MCH, Cuttack.

Population:

Pregnant women, who were visited for routine prenatal checkups to O&G OPD department of SCB, MCH, Cuttack, Odisha from August 2019 to October 2019.

Sample: 300 pregnant women were included in the study.

Sampling Criteria:

· Inclusion Criteria:

a. Attending O&G OPD, SCB, MCH, Cuttack, Odisha.

b. Available during the period of data collection.

c. Able to speak and understand Odia.

· Exclusion Criteria:

a. Not willing to participate in the study.

b. Not available during the period of data collection.

c. Did not give written consent to participate in the study.

Data collection tool:

A structured self administrative questionnaire was developed by the researchers for data collection to fully meet the demands of this research. The questionnaire was divided into three sections:

Section A: Demographic details were included such as age, educational status, parity and trimester, etc.

Section B: Q1-Q20 - to assess knowledge.

Scoring: Pregnant women’ total knowledge score was converted into total percent and graded as the following; poor when total score was (0 < 10), average when total score was (10 < 20) and good when total score was (20 ≤ 30).

Section C: Q21-Q30 - to assess the attitude of pregnant women towards cord blood stem cells and its banking. This tool was developed by the researcher after reviewing related literatures,^16,17 to assess pregnant women attitude pertaining cord blood collection and stem cells banking and consisted of (10) items such as (Collecting umbilical cord blood immediately after delivery is necessary, cord blood available for life, umbilical cord blood should only be used for baby and his own family . . . etc.).

Scoring: The items were judged according to a Three Point Likert scale continuum from agree (3), neutral (2), and disagree (1). Summing up the scores of the items then the overall score gave total attitude score. Nurses’ total attitude score was graded as the following; negative when total score was (1-10), neutral when total score was (10-20) and positive when total score was (20-30).

Content Validity:

The questionnaire was developed in English. The questionnaire had confirmed its validity in several studies with different backgrounds and refers mainly to UCBB. After that, the developed questionnaire, along with a request letter, validation certificate and answer keys were submitted to panel of Obstetrical and Gynecological experts in nursing and hematology medical staffs, Paediatrics, Nursing and Community Medicine for establishing the content validity. There was 80% or more agreement for 26 out of 30 questions and their wording, which were left as it is. For the other four questions, suggested changes were made. Odia translation of English version of the self-structured questionnaire was undertaken to have a clear and easy to read and express questionnaires in local language. Care was taken to keep it conceptually equivalent to the original questionnaire. The translation choices and quality of two translations were reviewed in the consensus meeting consisting of the investigator, translators and two experts in the subject (Translation report). Attention was given to the meaning of the words in the different languages to obtain similar effects. An effort was made to identify possible difficulties in understanding the questionnaire

Reliability:

The reliability of tool was established by testing the internal consistency. The internal consistency was assessed by using test retest technique. The reliability of structured questionnaire was (knowledge = 0.92 and attitude = 0.87). It was highly reliable.

Ethical Consideration:

The study proposal was submitted for approval and clearance was obtained from the ethical review board. Before the study, permission was obtained from the Superintendent, SCB, MCH, Cuttack, Odisha to conduct the study. A self-structured pretested and validated questionnaire was used in the study. Also, written consent was obtained from pregnant women before inclusion in the study. Participants were assured that all their data are highly confidential, anonymity was also assured through assigning a number for each woman instead of names to protect their privacy. Data was only available to the researcher and the participants.

Pilot Study:

After obtaining a formal administrative approval pilot study was carried out from 5^th August 2019 to 12^th August 2019 at City Hospital, Cuttack, Odisha to find the feasibility of the study on a convenience sample of 30 participants were selected randomly. The subjects for the pilot study possessed the same characteristics as that of the sample for the main study, but the pilot study participants were not included in the main study. Modifications were made according to the suggestion of patients to facilitate comprehension.

Data Collection Procedure:

Data were collected for main study from 300 pregnant women who came for routine prenatal visits to O& G, OPD departments of SCB, MCH, Cuttack, for the duration of 3 months. Participants’ who agreed to participate in the survey were assured of confidentiality. The personal right to withdraw from the survey at any moment was ensured. The participants were informed about the purpose of the study and consent was taken from the participants. A total of 300 questionnaires were distributed to patients and data were collected by interviewing the participants. Age group of the Patients' was between 15 years and 40 years. The patients were explained about the questionnaire before they answered the questions. The study participants were given 15 min to fill the questionnaire. Filled questionnaires were collected back immediately on the day of data collection. Data analysis was done using statistical software SPSS version 16. frequency and percentage was taken to assess the knowledge and attitude of pregnant women towards stem cells and its banking. Regression analysis was carried out to check any relation between the parameters. Any values ≤0.05 was considered to be statistically significant.

RESULTS:

A. Demographic variables:

Table 1: Demographic characteristics of the population studied.

Characteristics		No. of Participants	Percentage (%)
Age	<20 years	10	3.3
	20-30 years	198	66
	>30 years	92	30.7
Educational Status	Primary	88	29.3
	Secondary	200	66.7
	Graduation	12	4.0
Religion	Hindu	200	66.7
	Muslim	98	32.7
	Christian	02	0.7
Parity	Primi	146	48.7
Parity	Multi	154	51.3
Trimester	First Trimester	37	12.3
	Second Trimester	98	32.7
	Third Trimester	165	55

In the present study, among 300 pregnant women, out of which 10(3.3%) were < 20 years, 198(66%) were 20-30 years, 92(30.7%) were in the age group of > 30 years. 88(29.3%) had primary education, 200(66.7%) had secondary education and only 12(4%) were graduate. 200(66.7%) were Hindu, 98(32.7%) were Muslims, and 2(0.7%) were Christians. Totally, 146(48.7%) were primi and 154(51.3%) were multi. Among pregnant women attending OPD, 37(12.3%) were in their 1^st trimester, 98(32.7%) were in their 2^nd trimester, and 165 (55%) were in their 3^rd trimester.

B. Knowledge regarding UCB banking:

Figure 1: Assessment of overall knowledge of pregnant women towards stem cells.

C. Attitude towards UCB banking:

Figure 2: Preferred sources to gather information related to the issues of cord blood banking.

When asked from where or whom they would prefer to get the information on this issue, 52% wanted it from their obstetricians, 22% from UCB representative, 16% from the internet and 10% from family/friends

Figure 3: Distribution of women willing to donate cord blood stem cells.

Table 2: Co-relation of age, education and income with knowledge and attitude:

	Co-relation (r)	P-Value
Age -Knowledge	-0.236	0.000
Age -attitude	0.089	0.126
Education -knowledge	-0.601	0.000
Education- attitude	0.063	0.279
Income- attitude	0.108	0.061
Income- knowledge	-0.633	0.000

DISCUSSION:

In this study, 230 (76.7%) had no knowledge and 70 (23.3%) had knowledge about stem cells. However, in a study conducted by Fernandez et al.,¹¹ about 70% of pregnant women had a little or very little knowledge level. Similar results were seen with the study conducted by Vijayalakshmi¹⁸ in which pregnant women had poor knowledge score (95%) regarding collection and storage of stem cell and its banking. These findings were supported by Suen et al.¹⁹ The results of this study revealed poor and inadequate knowledge on stem cell banking and its applications among most of the pregnant women.

In this study almost all of the pregnant women around 80.3% had positive attitudes towards banking stem cells in public bank, due to less cost as compared to private bank.a study conducted by Fernadez et al.¹¹in Canada, where public cord blood banking is legal and widespread, 86% of the women preferred to use public banks for storage, which is similar to the present study.

In the present study, as age increased attitude toward stem cells and its banking increased, and it was statistically significant (P<0.05). Whereas age increased knowledge towards stem cells and its banking decreased and it was statistically significant (P<0.05).

Storing cord blood in private banks was impossible for the majority of population who could not afford the cost of private stem cell banks. In parallel with this study, women did not know about the cost of collecting and storing stem cells and its banking. For this reason, stem cell banks need to be funded by the government.²⁰ The majority of participants who wanted to be informed about stem cells collection and storage, wanted this information to be given to them by their obstetrician.

Limitations of this study were generalizability of study results is not possible. A bigger sample could have been taken not be done due to time and funding constraint.

CONCLUSION:

The majority of the participants had inadequate knowledge about stem cells and its banking and wanted to be informed. One of the goals of antenatal care should be to ensure that every pregnant woman has an opportunity to make a well-informed decision about cord blood banking.²¹ Active involvement by obstetricians would allow patients to be educated unbiased with more evidence-based scientific evidence to reach a greater number of potential donors without significantly increasing demands on the public banking program.

ACKNOWLEDGEMENT:

I would like to thank my Co-Author Dr. Laxmi Rana (PhD in Nursing), Research Supervisor, Himalayan University, Arunachal Pradesh for her constant guidance. I would like to thank my study participants, my Husband (Mr. Brundaban Sahoo), my loving Son (Mr. Bijay Kumar Sahoo) and friends for their constant support.

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Received on 19.05.2020 Modified on 29.06.2020

Asian J. Nursing Education and Research. 2020; 10(4):452-456.

DOI: 10.5958/2349-2996.2020.00096.8