Dear all:

Because I come from a public health background, I was used to looking at
breastfeeding in the context of the larger society and promoting it within
the  entire health care system.

I doubt I'd ever survive for more than a day in a hospital because I
couldn't tolerate the day to day grind of having to educate over and over
again those who might have control over the policies that might affect what
I would be allowed to do.  Its so much easier to have patience when you're
working from the outside as I used to do, with Ministers of Health, District
Health Officers, and Community Health Workers. At least then, the years that
it takes to slowly win them over to better practices for supporting
breastfeeding, didn't have an immediately negative consequence on my day to
day activities. If they disagreed, I didn't have to worry about losing my
job, I'd just plug away at them slowly over the years. So, for those of you
working in hospitals, I have developed an enormous amount of respect for
what you do.

I must confess, however, that I find some of the concerns over the split
between "medicalization" and "lay" counselors is probably due to the fact
that most lactation consultants in the United States do come from a hospital
setting where it is only natural that the medical concerns are far more
emphasized.  When I had my son, I thought that lactation consultants would
primarily come from a nutritional background because of the long-term
relationship that is developed while breastfeeding, rather than the
short-term initiation in the hospital. This obviously comes from the bias I
have about my own background.  I think there is a lot of room for building
bridges across professional backgrounds within the LC and lay communities.
We each share a perspective that is extremely valuable.


I do feel that the situation in breastfeeding is topsy turvy from the
developing country health care systems.  For many years, developing
countries suffered from a lack of community health workers.  They did have
some secondary and tertiary care facilities, but most people had no access
to these expensive facilities.  Moreover, there were not enough facilities
to go around.  Hence, there was a big push to get the sort of primary care
that most people need out to where it was needed.  So now the primary care
systems in developing areas of the world far more developed than 20 or 30
years ago (while it is deteriorating in the US).

Primary: I look upon the "lay" counselors as the front line of people who
are helping women breastfeed.  There should always be more "lay" counselors
because they will have closer access to women who need help for the entire
duration of their nursing experience and they can reach more women. Similar
to the primary health care workers in developing countries. I feel that La
Leache League provided the primary care to keep breastfeeding going on some
level in backward developed countries such as the US (as opposed to Norway).
 While it may have been considered "subversive" by those who consider these
wonderful dedicated women to be "breastfeeding Nazis", they kept
breastfeeding from entirely dying out during the era when medicine thought
they had outsmarted mother nature.  So, while I'm sure we'll all agree that
breastfeeding rates weren't what they should have been, La Leche League and
other lay counselors made sure it didn't dieout.

Secondary: I see lactation consultants as the secondary care system that is
just getting going.  For two generations of women in backwards developed
countries, if you had a clinical problem that couldn't be managed on your
own or with lay counseling, that was it.  You were encouraged to give
formula.  The profession is new, just developing its standards, and still
struggling with recognition.  I heartily endorse the comments of those who
have said that we cannot water down our qualifications.  We MUST work on
getting respect and that means maintaining high standards and having those
standards recognized. And as professionals, we should be maintaining bridges
with the primary care system - the lay counselors who are always going to
reach more women than we could ever hope to reach.  They should feel
confident referring women to us who need clinical care. And we should be
recruiting new members because are numbers are still woefully inadequate to
truly support women in backward countries where breastfeeding is not fully
supported, such as the US.

Tertiary:  I see breastfeeding medicine specialists as the tertiary care
system.  This area has been even more neglected than the secondary care
level.  All the women who happen to be the asterisks in the breastfeeding
books - the women with PCOS, tubular breasts with inadequate glandular
tissue, messy infections who don't get proper treatment, etc. These are
areas where the IBCLC needs an MD (or and IBCLC MD) to back them up with
appropriate treatments for these women. Its appalling that there is only one
breastfeeding medicine specialist that works in a city the size of Manhattan
- and a handful of obstetricians who dabble in this area.  I found it
terribly arrogant and disturbing when one of the endocrinologists at the ABM
meeting last year bascially said there is no treatment for endocrinological
issues that cause low supply. In a country where we have specialists for
every single body part down to our toenails and you can reshape your breast
into any form you think is beautiful, it is ridiculous that women can't get
help when they truly have some primary problem with the true function of the
breast in producing milk.

The support system for women trying to breastfeed is incomplete without all
three areas working well and working together with each other.

So, whereever you are on the spectrum from lay counselor to specialized
breastfeeding medicine specialist, think about how to build bridges to the
others whose skills you may not yet be confident about - but may either be
better than you think or might florish with appropriate dialogue.

Susan E. Burger, MHS, PhD, IBCLC

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