I agree that the issue of qualifications is a thorny one, and that the public
is often clueless believing that all lactation consultants are the same.  The
sad thing is for a mother to consult in good faith, be told that "your
positioning looks great" when it isn't and her nipples prove it, and feel
that there is something wrong with her when breastfeeding fails.
 Unfortunately this may occur even with someone who has been able to pass the
IBLCE exam.  I have been concerned that there are people sitting for the exam
who count as contact hours every hour they've ever been around babies -- even
if they were practicing BAD bfg support during those yrs. Altho I will grant
you have to start somewhere and we'll all get better if we "prctice" long
enough :-) I am also concerned when people don't keep up with the literature,
and fail to look at related specialites for new insights (nutrition, OT/PT,
massage, psych.)  I think that it would be wonderful to confer Diplomat
status on LCs re-certifying at 10 yrs with a much more difficult, advanced
exam.  If I can't pass the same exam I took 10 yrs ago after that many yrs of
practice and all those CE hours then I probably should retire.

One partial remedy to the LC shopping (by price only) is just to put in the
long, hard work of reputation building in your community. I don't know that I
am even listed on the 800 number any more.  I really have grappled with that
one as it does imply that all are equal --sort of like who is the closest
roto-rooter guy.   Mothers do listen to their doctors when the referral comes
from them.  Sending prompt MD reports, being thorough with follow-up, trying
to personally meet some of the MDs are ways I work on the referral side of
things. Day in and day out you just do your level best to ethically and
intelligently care for every mother and baby.  This guarantees nothing,
because a boutique renting pumps may drive you out of business tomorrow, and
people shop for price not service no matter what the pump cos tells you. But
at least you can sleep at night.
.
We are probably going to have to confront (as a profession) the consequences
of "too much success" in terms of how many we are certifying.  Its a quandry.
 We want more and better trained helpers for moms, but there is really only
so much market for (esp.  priv. pract.) LC services based on the local
birthrate, etc.  In a fair market, it is survival of the fit, which adds a
level of competitiveness that feels awkward for those of us who see our work
as more of a calling than anything else.  Hard choices about whether to stay
in it may occur if family financial considerations force the issue.  I think
its a good issue to hash out in this forum.

Barbara Wilson-Clay, BSE, IBCLC
priv. pract. in Austin, Tx (but I went to high school in Cleve. and just want
to say WAY TO GO INDIANS!)