Steven B. Larsen

Director, Center for Consumer Information and Insurance Oversight

Centers for Medicare & Medicaid Services

200 Independence Avenue, SW

Washington, DC  20201



Via Electronic Mail



Re:  Essential Health Benefits Bulletin



Dear Mr. Larsen:



“A stitch in time saves nine.”  “Crying over spilled milk.”



Ancient expressions speak of essential economic and emotional realities.
Loss.  Regret.  Waste.  They date to times when margins of survival were
much narrower than they are in the United States in the twenty-first
century.  They date to times when small losses could lead to bigger losses
often and swiftly.  Margins of survival have narrowed recently in the
United States and worldwide.  The U. S. infrastructure has offered a
blessed cushion, but everyone is aware that common resources have to be
expended wisely to prevent loss and waste, or we will regret it.



Breastfeeding occupies a unique economic and emotional position in society.
It nourishes infants while they acquire the digestive and immune capacities
necessary to grow and survive.  It bonds infants to mothers and mothers to
infants, providing a strong hormonal foundation for the nurturing behavior
necessary for children to learn.  Its loss puts an infant and the family at
an immediate disadvantage.



Breastfeeding occupies a unique position in time.  Each hour after a
child’s birth that breastfeeding is not in place is time lost in the
development of the child’s digestive, endocrine, and immune systems.  Each
hour that breastfeeding is not working causes loss of milk gland function
that is difficult to recover.  Timely help when breastfeeding is
complicated can make a huge difference in whether a mother succeeds in
establishing breastfeeding.



I have been a mother and a La Leche League member since 1985, and a La
Leche League Leader since 2001.  I have been working the past year as a WIC
Breastfeeding Peer Counselor at my local health department.  After years of
continuing education, I recently certified as an International Board
Certified Lactation Consultant (IBCLC).



In my volunteer and Peer Counselor capacities, I often encounter moms who
need intensive postpartum help to establish breastfeeding.  With my recent
certification as an IBCLC, I am aware of the knowledge and skills that
cannot be counted on from other practitioners.  I am aware of IBCLC
procedures that maintain the follow-through, within the family and with
health care providers, that is often crucial to a mother’s breastfeeding
success – and to her and her baby’s health.



In the United States in the twenty-first century, mothers and their
newborns go home from the hospital very soon.  The privacy and familiarity
of home can be good for breastfeeding, but isolation is not.  Often, a
postpartum WIC client has some combination of the following:



Far from extended family, or the father of the baby is not available

Language barriers making phone help difficult

Recovering from surgery

No help with older children

Husband has few days off from work

Husband has the family vehicle during business hours

Husband has the family’s one phone while at work



These women do not have the means to return to the hospital for outpatient
help or even to get to the WIC clinic in a timely fashion.  Too few
hospitals and WIC clinics have enough IBCLC availability to serve all the
mothers who need their help.  And importantly, *a mother should be helped
in the context where she will be caring for her infant*.  Without seeing
the mother’s home, a breastfeeding helper of any stripe will have great
difficulty perceiving what domestic realities are affecting a mother’s
recovery from birth and care of her infant.  This is true even of mothers
with more resources.  IBCLC services should not be available only when
billable to an institution!



The CDC recommends that lactation support be “included in standard,
reimbursable perinatal care services.”  The Surgeon General recognizes
IBCLC’s as “the only health care professionals certified in lactation care.”
I recommend that all insurance payers put people with backgrounds like mine
to work serving mothers when and where they need it most.  Many of us wish
we were independently wealthy so we could finance our continuing education
and malpractice insurance, and support our children, while serving *pro bono
* all the mothers whose breastfeeding struggles we become aware of.  But
most of us need to be compensated for our time, so that our skills – and
the milk of U. S. mothers – will not continue to be underutilized resources.



Earnestly,



Ruth Piatak

-- 
Ruth Piatak, BA, MS, LLLL, IBCLC
WIC Breastfeeding Peer Counselor
Tulsa, Oklahoma
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