"And so I will respectfully disagree:  I do not think the efforts by IBCLCs
to obtain licensure, as a measure of better reimbursement for and paid
recognition of their role **as health care providers** will diminish, one
whit, the fine role (indeed the crucial role) that peer counselors play."

Licensure means that to do something, in this case some form of breastfeeding/lactation counseling, one would need permission - a license. It means that people without a license will not be allowed to perform breastfeeding/lactation counseling.

"Nurses are licensed, OB-GYNs are licensed, midwives are licensed,
pediatricians are licensed, neonatalogists are licensed, OTs are licensed,
SLPs are licensed, chiropractors are licensed, massage therapists are
licensed, acupuncturists are licensed.  Their role in the healthcare field
does not diminish the need for or role of the LLL Leader or WIC peer
counselor or any other kind of mother-to-mother counselor.  Adding
licensure for IBCLCs won't make a difference, either."

LLL do not do anything that nurses, OB-GYNs, pediatricians, etc. do. Otherwise they will be breaking the law. However many areas of work between IBCLCs and LLL Leaders in fact intersect and blend. The boundaries are not clear. Not yet. IBCLC licensure will force very precise and clear definitions and descriptions for scope of practice for both IBCLCs and any peer support person who will be doing any breastfeeding counselling. The possibility of the same activities for Leaders and IBCLCs being both in licensed and unlicensed areas are highly unlikely. It will then defeat the point of licensure. It is hard to predict the exact extent of impact of IBCLC licensure on peer support, but it will make a difference. We have enough well documented research on medicalization of birth and outlawing midwives by licensing physicians to attend to all matters related to pregnancy and birth.

"I disagree with Stanley Gross's article about licensure on one major
element:  he argues that "the generally stated purpose for licensing and
the primary justification for this use of the police power of the state is
to ensure quality in services offered to the public."

I argue that licensure is an exercise of the state's power **to protect the
public's health, safety and welfare.**  It is the "hook" by which the
states are allowed to legislate and regulate free (professional) trade: if
people are going to go around playing nurse, doctor, or midwife, affecting
the health of mothers and babies by the care given, we (the state) had
better make sure they have passed some minimal measures of competency.

And critically, if they can NOT demonstrate those minimal measures of
competency, we (the state) need a disciplinary and sanctions procedure that
allows us to wrench that license from the "lemons," so they don't go on to
misinform or indeed even harm more mothers and babies."


Stanley Gross provided overwhelming evidence that shows that licensure does not correlate with quality and certification accomplished similar goals. The public belief is that licensed providers mean safety and wellfare. The research shows a different picture. He does specifically provide research that shows that there is a very low percentage of disciplinary procedures against healthcare providers and that the number of lawsuit claims against healthcare providers does not decline with licensure. If there is any other research overview that shows something different, I would like to see it.

"I don't think licensed IBCLCs will prevent mothers from finding and using
excellent mother-to-mother volunteers.  I do think licensed IBCLCs will be
able to be reimbursed for their services, making them attractive employees
to have on a hospital staff.  For the discharged mom with private
insurance, skilled lactation support is henceforth a benefit with NO
out-of-pocket expense for the mother, under the ACA."

I argue that mothers will find a different quality of services provided in lay, peer, or volunteer sector. The depth and breadth of help in peer support sector will most likely decline.

"Medicaid will ONLY reimburse licensed providers.  >50% of USA births today
are to mothers who are WIC-eligible and whose children thus are
Medicaid-eligible.  Without licensure, *no* IBCLC will be able to provide
care under the Medicaid-expansion portions of the ACA (which are a much
bigger part of that complex law than the private insurance requirements).
 That means an awful lot of women will not receive care from an allied
healthcare provider whose singular specialty is human lactation."

US healthcare is in the state of flux today. It would seem logical that legislation can be changed if one can prove a point that licensure of IBCLCs for reimbursement purposes is not enough proof that the public will benefit. If we draw upon research on medicalization of birth and what it has done to access to midwives, one could foresee similar scenario repeating itself with breastfeeding. If the government call is to establish peer support networks and licensure has potential of negatively affecting Surgeon General's Call to Action to Support Breastfeeding, then it would seem logical to change approach to how healthcare reimbursement works, at least in this area.

"Tossing aside my admittedly-selfish reasons to find job security, decent
compensation for my skill, and a stable future for the IBCLC profession, a
very real concern is that those >50% moms ain't gonna be able to see me or
my IBCLC colleagues."
There is nothing wrong with having selfish concerns. Framing desire for licensure around feminist issues of compensating women for traditionally female skills and knowledge could go down in history as a noble event. Seeding IBCLC in the hospital for the " >50% of USA to mothers who are WIC-eligible and whose children thus are Medicaid-eligible" is not a primary concern. Their real concern is how to survive and put food on the table of their children, now to find jobs, and how to raise those children. 2 days of IBCLC help in the hospital will not change the fact that those mothers may have to go to work straight from the birth chair and struggle for breastfeeding is low on women's priorities in the larger picture of survival on the margins of society.

"IBCLCs have tried certification as the primary route to establish credibility and appropriate compensation. It hasn't worked."
Surgeon General recognized IBCLCs in her document. I would not be this pessimistic. The fact is that the credibility of medicine and physicians is on the decline. Hospitals are run by administrators who make every practitioner quite unhappy, including physicians. IBCLCs are not the only people around with the feeling of being unappreciated.

"Indeed, in 2012 we find ourselves now with such a muddled and confused marketplace, with so many Not-Quite-IBCLCs claiming they have the same training and skills as IBCLCs, that mothers really ARE finding their "health safety and
welfare" is at risk."
There are people who are not IBCLCs who have comparable set of knowledge and skills. It is a fact of life and it is good for the public to have a wide choice of people who have those skills. Most women go for help to those places and people who helped other women. It is word of mouth. IBCLC is not a guarantee for safety and welfare just like physician is not a guarantee for safety and welfare. One has an equal change of encountering subpar healthcare provider as encountering a good one. It is a matter of luck most of the time. Word of mouth works wonders. You establish a reputation and people come to you because you helped somebody else, not because you have credentials. 

"I welcome thoughts on alternative routes to assure that mothers who require it receive IBCLC care, and that IBCLCs are fairly paid for their time  and service as allied heathcare providers."

What are the chances of arguing a point that licensure will restrict other areas of breastfeeding support based on existing knowledge we have of what happened to birth and presenting research that certification is adequate enough and good for economy and the public? I understand that current legislation makes breastfeeding support a requirement. The question remains how to get adequately and fairly compensated for services. In fact Surgeon General's Call to Action states 
"Provide reimbursement for IBCLCs independent of their having other professional certification or licensure. The taxonomy for health care clinicians defines qualifications of clinicians to be reimbursed. One option for reimbursement would be to place certified lactation consultants within the category of “nursing service related providers,” and specifying the nature of care they provide would allow for reimbursement of IBCLCs without requiring that they are also registered nurses." Licensure is proposed as an alternate route, but I am not sure they gave it a though on how it will impact society as a whole.

Natalie Wilson

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