At further risk of undermining my own credential, I have another concern about this idea. While Judy addresses many important points as to the immense barriers faced by breastfeeding mothers in the US (and similarly here in France and I daresay much of the West), I am not convinced this would solve much of anything. 


Judy wrote: "So, I believe that an IBCLC in the primary care practice can give families correct information, and more importantly, the confidence to continue to breastfeed."

I know this will sound negative, but I am not convinced that the majority of those who now have the IBCLC credential are giving mothers accurate information. If you read the blog post that Jean Cotterman posted here a couple of weeks ago (http://temerity-jane.com/life/was-almost-stirred-to-something-kind-of-resembling-a-bleached-out-version-of-mild-righteous-outrage/#comments), or read any of the breastfeeding pages on FB, you know that mothers are getting awful advice from IBCLCs (and others calling themselves LCs). And, while we could argue that mothers are "misinterpreting", etc and of course that sometimes happens, it's no different in my mind from responding to a near-40% cesarean rate with the comment "Well, some mothers need them". It's a straw man argument not worthy of anyone who works with moms and babies. 
I have witnessed this problem myself. There is barely a day goes by that I am not on the internet being asked by someone to look at pix of their babies' mouths who have been told by IBCLCs that their babies are not TT'd.  I live in France and yet in the past month I have sent mothers from Canada, NJ, OR, FL, NY and AR in the US to doctors who revise properly. All of them had seen midwives, LLLLLs, IBCLCs and of course their own peds and sometimes other specialists (such as an ENT). Most of these mothers have suffered a very long time as have their babies for lack of proper treatment.
That's just one issue. Gut health is really my passion and I see too many mothers given the most atrocious misinformation by IBCLCs about their babies' "colic" or allergies or "reflux". Breastfeeding is the foundation of well-being past the post of gestation (which is the true foundation) and yet while we bemoan the nutritional knowledge of physicians, ours as a profession  is no better. I am working with a mom right now who is healing her gut for the sake of her baby and is blown away (this is her 2nd) with how amazingly healthy and energized she feels. I have alway said that Nature is not flawed and did not design us to be too exhausted to mother. Our poor nutrition has done that. 
So, with all due respect, as much as I am appalled at US (Western) birthing practices (I did have all homebirths for that reason) unless we are willing to have more to offer these women who, IMO are generally in poor health having babies, I am not sure how much it will matter that we can fix a latch. And, honestly, if I have to spend 20 minutes explaining to one more mother that poop is 50% microbes and therefore cannot be "all used up" and that babies must NEVER skip a day of pooping, I might lose my mind. ( blogged about it, if anyone wants to read it: http://holisticibclc.blogspot.com/2011/06/gut-microbes-and-poop.html). 
Judy: 

"Additionally, it is not the norm for the hospitals in the US to have adequate breastfeeding support available for their patients. There are rarely enough IBCLCs to attend to the number of birthing women because the US the health care system is based on third party reimbursement."
This is of course so true, however, so long as the priority is to hire RN-IBCLCs we will continue to see RNs picking up this credential with none of the knowledge as to how their interactions in hospital play out in the post-partum world. And so long as hospital-based IBCLCs feel that it is acceptable not to give mothers certain ACCURATE!! information at the risk of losing their jobs, then how is seeing these IBCLCs a benefit anyway? Who does not hear over and over that mothers saw more than one IBCLC in hospital and got conflicting info? Who hasn't heard that mothers did not seek help after discharge bc they saw an IBCLC in hospital and thought that was all the profession could offer them?  Even the most dedicated, experienced IBCLC in hospital has very limited time to offer and can barely address the basics. Who in out-patient does not take  1 1/2-2 hours to do an intake appt? Because that is the minimum to provide adequate care, IMO. 
If in-hospital care assumed follow-up at-home care, then I think we would be onto something, but in fact it often precludes mothers from seeking additional care, based upon their expectation of what an IBCLC provides.
Judy:  So,I believe that an IBCLC in the primary care practice can give families correct information, and more importantly, the confidence to continue to breastfeed. "

In theory, I agree, Judy, but not in practice. I cannot tell you how often I have cringed when my clients have come back from the "LC" at their ped's office and everything I have told the mother has been undermined. Further, how many peds are Jay Gordon or others like him who fully trusts his IBCLC and supports the parenting practices we know make breastfeeding work for more than a few weeks? 
I so agree with you Judy, but I think that before we make the argument that everyone needs an IBCLC, I think we need to drastically expand the education of all IBCLCs. The old tricks often do not work anymore--not in a culture where women truly have "nothing against formula", where breastfeeding is viewed as "optional", "ideal" and militant" and something to be done under "hooter hiders", where sick women are having sick babies, where inductions and every other medicalized intervention is the norm (and women who do NOT want to change their birth practices want breastfeeding to be "natural"--such that breastfeeding is now viewed as "hard" by just about every mother) where poor gut health is, IMO, the health care issue of our entire population and where, of course, lack of parental leave handicaps everyone from the outset. 
Jennifer Tow, IBCLC, France, Intuitive Parenting Network, LLC

Thank you for sharing your wise opinion with us Rachel as always. I

certainly agree with and admire your vision, especially the part about
IBCLCs being in policy making positions. I should have qualified my thoughts
as pertaining to infants born in the United States rather than just saying
"Where I practice". In the US most babies are born in the hospital and
newborn care happens in a medical setting where they are followed by a
general practice or pediatric physician once discharged. As we both agree,
birth is medicalized here and needs improvement or completely overhauled,
but that is a separate battle altogether. While I personally had midwife
births and understand this and advocate for it, I am more concerned with
caring for the families presented to me now and what I can do to help these
mothers and babies in spite of the birth circumstances which have passed. I
am one of the roughly 20% of US based IBCLCs who works in the out patient
setting and this is the environment from  which I speak. I have 15 years
working on a breastfeeding helpline and in private practice and 5 years in
pediatric practices. Though I know how inadequate telephone helping can be,
I have supported hundreds, of women as best as I could via telephone because
no other option was available to them. As evidence for my desire to make
breastfeeding support easy to access and integral to health care in the US,
I cite the poor breastfeeding duration rates that can be found on the CDC
website as well as the work of Ruowei Li, Sara B. Fein, Jian Chen and
Laurence M. Grummer-Strawn, During the First Year Why Mothers Stop
Breastfeeding: Mothers' Self-reported Reasons for Stopping Pediatrics
2008;122;S69-S76. 75% of US mothers attempt to breastfeed, but few are able
to continue to their desired goals.

 

I rarely see an infant that was born without anesthesia, without pitocin
exposure, without separation from the mother or other troublesome
interventions. The difference in feeding instincts and ability of mother and
baby are profound for those who manage to avoid intervention and be born
naturally. These rare few really don't need an IBCLC to do anything to help
them feed. However, even with an ideal birth, they live in a culture that
generally does not trust the process of breastfeeding and will receive lots
of negative messages about breastfeeding and plain wrong information from
the people who surround them. Many normal newborn behaviors will be
mistakenly interpreted as breastfeeding problems. Many need anticipatory
guidance about use of hormonal birth control or medications or returning to
work. There are many cultural breastfeeding practices in the US that mothers
accept without a second thought that can undermine breastfeeding. Most will
not seek out, or find, any type of lay breastfeeding support. Because I am
available to them in the health professional setting, I have credibility,
even though I might say the same thing at a La Leche League meeting in my
role as a lay volunteer, the perception of the information is different. So,
I believe that an IBCLC in the primary care practice can give families
correct information, and more importantly, the confidence to continue to
breastfeed. 

 
               Additionally, it is not the norm for the hospitals in the US
to have adequate breastfeeding support available for their patients. There
are rarely enough IBCLCs to attend to the number of birthing women because
the US the health care system is based on third party reimbursement. In
hospital settings, third party reimbursement is not given for IBCLC services
so this care is rolled into the total cost of maternity care. For the sake
of the bottom line, hospitals will often cut lactation care which is seen as
a non-necessity. For more information about these inherent problems see the
documents on the USLCA homepage  <http://www.uslcaonline.org/>
www.uslcaonline.org; Containing Health Care Costs Help in Plain Sight, IBCLC
Staffing Statement, and Five Steps to Improving Job Security. Due to these
reasons, many mothers have not received even good basic breastfeeding
support and information as part of maternity care. They are usually at home
before the milk comes in and that is when the problems become apparent.
www.BestforBabes.org is a good website to help those who live outside of the
US understand the unique challenges, and the "booby traps" women face here.
Lactnet also had a recent link to stories on blogs that would give insight
into the problems women face which in my opinion are  heart wrenching. 
http://temerity-jane.com/life/was-almost-stirred-to-something-kind-of-resemb
ling-a-bleached-out-version-of-mild-righteous-outrage/#comments 
 

 Once mothers are at home with their infants, they encounter problems
diagnosed in the medical setting where they receive routine care such as
weight loss, jaundice, breast / nipple pain, engorgement, low milk supply,
infant fussiness and so on. All of these are blamed on breastfeeding and
without breastfeeding support the baby is weaned to formula. Many of these
problems do require professional IBCLC support, some do not. But mothers
also cannot wait for the next monthly La Leche League meeting or the next
weekly WIC appointment to see a peer counselor to have the problem
addressed, even when that support would be sufficient to fix the underlying
problem. Lastly, Rachel says "But I would settle for just knowing that all
staff will refer to the next level of specialized care without delay". This
is unfortunately uncommon in the US unless a mother happens to live where
there are IBCLCs in private practice, knows how to find them, AND she can
afford to pay for their services out of her own pocket. Hospital referrals
systems consist of a list somewhere in the bag of formula and papers a
mother brings home with her. If she has remembered to look among this
"stuff", she then has to make phone calls to find help and figure out how to
pay for services. The available lactation consultant may be many miles away.
It is hard for mothers to take their babies on long rides to get needed
support.  Additionally, our public health programs that promote
breastfeeding rarely provide necessary IBCLC services for mothers who
encounter difficulties. One study cited 30% of mothers as having significant
problems that would require these services. 

 

            I see the IBCLC in the out-patient primary care setting as a
preventive health care provider. I would rather see the few mothers and
babies who absolutely don't need any IBCLC services have an unnecessary
visit, than have many not get care they do need. I know that there are
fewer, and less severe, breastfeeding problems presenting to me on a regular
basis now that I am working with mothers routinely within the first 1-2
newborn visits. Previously, I worked in private practice where the mothers
didn't find me until the problems had been ongoing for two or more weeks. By
that time milk supplies that could have been normal are low due to poor
breast stimulation and babies have no energy due to weight loss and their
feeding skills have declined due to supplementing, and so on. The longer a
breastfeeding problem is not recognized and managed the harder it is to
normalize. Additionally, problems crop up later in lactation; biting,
oversupplies, allergies to proteins in mother's milk, nursing strikes, low
milk supply and so on. Because I am known to the mothers and accessible to
them in the familiar and local setting, the mothers contact me so these
problems can be overcome with support and correct information.         

 

               In the long run, providing effective breastfeeding support as
preventive health care will save billions of dollars in health care costs
for infants and mothers, much suffering that goes along with these illnesses
and lives of both as well. If that wasn't enough, mothers with this kind of
support have less anxiety over feeding and caring for their infants during
this important threshold in their lives. Maybe they will have less
postpartum depression too? Do I have data to support this opinion? No,
unfortunately not. But I have the cards, emails, phone calls, smiles and
tears of relief from many mothers, fathers, grandparents and even fellow
health care providers that prove to me the value of being available in their
time of need. I don't need numbers, but I hope to some day have the
opportunity to do the research to prove what I believe. Stay tuned. 

Judy



 
 

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