The large number of messages concerning the IBLCE SOP and the value 
of the IBCLC certification has been very educational.  I have been 
very interested in how everyone "sees" the conflicts and anomalies 
and indeed there are many.

Firstly, a brief background. I am "only" an IBCLC.  I used my 
credential as a private practice IBCLC in Zimbabwe from 1991 - 
2003.  Clutching my brand new certificate in 1990 I presented 
myself  within days to the Health Professions Council only to be told 
that I didn't have "a snowball's chance in hell of being 
registered".  The main reason?  I hadn't received a recognized form 
of training. The Registrar did, however, volunteer the information 
that this was a double-edged sword;  not being registered meant that 
my activities could not be regulated by the Council, so I was free to 
practice.

Because there was an existing breastfeeding culture (well over 99% 
initiation, 23% of 2 year olds still breastfeeding) which was 
strongly supported and enforced by government policy I was seen as a 
useful practitioner, not an advocate.  I received referrals, had 
hospital privileges and was treated as one of a team, who were all 
working for the best health outcome.  I wouldn't have dreamed of 
contradicting a doctor. In the very few cases where a GP or an OB had 
given advice that didn't seem evidence-based or helpful, I was able 
to contact the baby's paediatrician to obtain his support for 
offering alternative information - often with the specific request 
that I update the GP/OB.  Obviously, I tried very hard to do this as 
tactfully and professionally as possible, citing references, sending 
photocopies - it worked.  Often GPs and OBs would ask me for info 
they couldn't locate themselves.

The point is that in this very baby-friendly environment, the LC 
could call on the evidence and expect that the physician would be 
required to use the same evidence.  There was policy back-up - 
political will.  I hear on LACTNET again and again how 
paediatricians, say in the USA, support formula feeding and how LCs 
are unable to contradict this medical advice.  Surely, though, the 
SOPs we're discussing don't preclude the IBCLC from offering 
up-to-date research and guidelines in support of protecting and 
maintaining breastfeeding?  If this is not the case, do I understand 
correctly that MDs and OB/GYNs and pediatricians in the US (or any 
other country) are able to give so-called "medical advice" which is 
clearly not only harmful to health but also out of date???  It occurs 
to me therefore that the "fault" here is not with the IBLCE SOPs, but 
with a health insfrastructure that does not require breastfeeding to 
be endorsed as an absolute health requirement, but sees it through 
the eyes of a bottle-feeding culture;  at best an optional extra;  at 
worst condoning medical "advice" NOT to breastfeed, which IBCLCs are 
unable to contradict.  What is the solution?  Perhaps to strengthen 
Dept of Health initiatives to protect and promote breastfeeding - 
including the logical requirement that primary healthcare providers 
should be prevented from giving out-of-date non-evidence-based infant 
feeding "advice".

Secondly, since moving to the industrialized countries I am gradually 
learning, with increasing dismay, that non-nurses are simply not 
employed in hospitals and doctors offices as IBCLCs.  The IBCLC 
position is often advertised in job descriptions, but the bottom line 
is that only nurse-midwives can apply.   Even in private practice in 
Zimbabwe, I was almost never able to have my fees paid by the health 
insurance companies, and I note that those IBCLCs who are lucky 
enough to obtain third-party reimbursement in UK and in Australia 
(and in the US?)  do so primarily through their RN (or other) 
qualification, not because they are IBCLCs.    In effect, because it 
is not their IBCLC certificate which brings in the $$$, perhaps it is 
fitting that they should be bound by their other professional 
standards and guidelines in earning them?    Perhaps this is at the 
basis of the ruling that "only" IBCLCs, with no other certification 
should be bound by the IBLCE SOPs??  Once again, it seems that the 
"fault" is not with the IBLCE Board, but with a global healthcare 
system that doesn't yet recognize the IBCLC credential.

The sticking point to recognition seems to be the type of training 
seen as sufficient by licensing boards, health professions councils 
and other healthcare providers who need to be reassured before 
referring on to a "consultant" who is not also a something-else.  As 
a non-nurse, non-anything-else, I find this infinitely regrettable 
but it seems that we are at a cross-roads.  I feel that the Board 
could take a more active role in seeking recognition of its own 
credential as a stand-alone certification, perhaps to provide "proof" 
that the experience gained in the voluntary breastfeeding-support 
organizations, and perhaps through distance education, is 
sufficient.   And to address the situation where employers advertise 
for IBCLCs with no intention of hiring them in that capacity.

Pamela Morrison IBCLC
Rustington, England

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