I have been following this thread with interest, and would like to add my
own thoughts.

I think that certification with a strong professional organization and
international standards for practice are probably better ways to maintain
quality assurance than licensure.  As a first RN, now CNM, I am licensed
to practice in my state.  To be licensed I had to pass board examinations
and prove that I had graduated from an accredited program.  However,
after that, as long as I pay my licensure fees and show that I have
maintained appropriate continuing education to support my continuing to
have prescriptive authority, that's all I have to do to maintain my
license. It is thru my professional organization -- the American College
of Nurse Midwives -- that quality assurance is really handled. In order to
maintain my certification as a CNM, I have to either retake the certifying
boards every 5 years or document a certain amount of continuing education
every five years.  Also, there is a mechanism for peer review and members
are required to participate in the peer review process!

Licensure, by itself, as many have pointed out, is not an assurance that a
practitioner is going to be decent.  I believe that certification
requirements for continuing education and peer review are more effective.
Licensure requirements in the US vary from state to state in what they
require of different professions, including physicians, nurses, and
nurse-practitioners.  In Washington State now, a new grad or recent
newcomer to the area, can't become licensed as an Advanced Registered
Nurse Practitioner of any flavor (there are many: CNM's, Pediatric Nurse
Practitioners, OBGYN Women's Health NP's, etc) unless one has a master's
degree.  Now why is this? The State Board of Nursing in all its wisdom
decided we all had to have our MSN's as a measure of educational
competence.  The result? Increased cost of education, increased barriers
to those wishing to enter the field, increased barriers to those already
disadvantaged by color, poverty, or unfortunate enough to live in a rural
area. But in California, I could be a CNM with only a two year nursing
degree with essentially the same scope of practice.  Hmmm....  If
licensure becomes a prerequisite for those wishing to practice as LC's,
then LC's will also have the opportunity to have arbitrary regulations
imposed by government boards who may or may not have a clue about what
really is entailed in maintaining high quality practice.

Re decreased clinical hour requirements for those with increased
education:  As an IBCLC who becamed certified only after she had been an
RN for a couple of years (though I had many years of experience counseling
in the community), I was darned glad to have my eductation count for
something!  In the real world of work, a two year RN can make as much
money as I do as a BSN. I got my BSN because I was planning to go on to
become a CNM and saw the trend to more and more programs being Master's
level.  Hopefully, the idea is that education does provide one with a
structured and verifiable way to gather knowledge from a wide variety of
sources and the exam is a way to test whether, at least, the didactic
information possessed by the applicant meets entry level criteria.  I know
of no profession that expects applicants trying to enter it to demonstrate
beyond entry level knowledge.

I don't know how many of you out there practice solely as Lactation
Consultants. Where I live, this would not be feasible.  Lactation
Consulting, for me, is one part of my clinical practice -- something I
take seriously and something which is important to me but still, one part
of a wider base of practice.  In my experience, it is difficult to get
reimbursed by third party payors for "lactation consulting" because it is
not valued as such.  As a CNM, I am actually in a much better position to
get reimbursed than previously because of my widened scope of practice.  I
have actually considered not continuing my certification as an IBCLC
because the requirements for continuing education are actually stiffer
than the ones for ACNM, the actual financial payback for maintaining the
certification is much less, and with the need to maintain a certain number
of hours of pharmacology education as well as the need to keep up in a
wide variety of topics to practice responsiblely in the rest of my
practice, it gets expensive and time consuming, and it begins to feel abit
overwhelming.

I didn't mean for this post to become ranty. I just am concerned about
people wanting it to become harder to enter and maintain a profession
where it is already difficult for many of us to get paid or recognized or
to have the time or money to continue meeting the present requirements.
I think that, thus far, a fine job has been done of making it possible to
enter thru multiple paths so that community breastfeeding helpers with
years of experience but not much in the way of degrees are able to sit for
the exam as well as those of us who have jumped multiple hoops
educationally and professionally in other areas.  I wish that midwifery in
the US had it so together as there is always ongoing arguments about entry
into midwifery via nursing vs direct entry, etc.  Quality assurance is an
ongoing concern or should be in any profession.  Mechanisms
for peer review may be a more effective tool than upping the educational
or certification ante would be.

Ione Sims, CNM, IBCLC