Cynthia asked about roots of LCs and the proportion in nursing and LLL

The last time I looked at any of the available statistics was probably at least 8 years ago.  I think I looked at the proportion who were in a) hospital or medical based settings, b) public health settings, and c) private practice.  I can't remember what the parameters were at the time and that would be VERY important to consider.  

I think this is particularly important to consider because when I looked into the prior survey done on the reimbursement rates for IBCLCs in the US, the survey was flawed in that it a) never directly asked specifically if the respondent was an IBCLC (many respondents actually comment that they were not) the question asked what was the requirements of the profession and gave a series of mixed credentials, eg.  RN, RN-IBCLC, IBCLC, etc. Since respondents may have exceeded the qualifications of the position or in the case of lactation consultant owned practices -- they may not have set qualifications -- the "qualifications of the position" cannot be assumed to be the "qualifications of the respondent".  Furthermore, I LLLL was not on that survey.

Furthermore, I have discovered that there are many interpretations of "private practice" including a) working for a hospital based outpatient clinic, b) working for a pediatric practice, c) working predominantly in the hospital and SOMETIMES seeing clients.  

Quite frankly, I think the IBLCE should be tracking their own statistics on who is applying to take the test and who becomes IBCLCs.

I think we also need to consider more than JUST the peer support model and the large institution model.  We are leaving out another very important group -- the entrepreneurs who often think outside the box and INNOVATE.  When I worked in international nutrition -- small pilot projects were very important for figuring out models that DID and did NOT work.  Just like Charter schools, many of the small pilot projects fail, just like there have been at ton of computer start up companies that failed but those that survived have created tremendous changes.  The difference between how I looked at this when I was working in international nutrition and how some politicians look at charter schools is that the PILOT PROJECT was meant to be just that.  Once you found those models that worked, you looked at ways to SCALE UP the projects.  Again, at the level of scaling up there were many failures as well.  Some projects just don't scale up or are so expensive that it is not viable.   One could look at this in a different manner of viral transmission of small projects -- which would work for some types of projects and looking at how to TARGET some of the small projects to areas and populations where they are most likely to work and use other models for different populations ans areas.  Or ADAPT the models to different cultures.

Again,  LLL evolved during and unprecedented era when for the first time in human history there was a sufficient middle class that women spent less time on economically productive activities (I think people forget that when you work on a farm feeding the chickens, tending the garden, educating your children in household tasks that you ARE working at activities that are economically productive because your family gets FED) and were able to VOLUNTEER.  While some of us do have the luxury of volunteering or sometimes are pressured into volunteering even when we really are overworked (here in Manhattan the pressure on women to volunteer for school activities such as auctions is really over the top), I do not believe that we should continue to rely solely on the VOLUNTEER model.  

Similarly, while the evidence is very clear that peer support does help breastfeeding, I have my own anecdotal evidence that peer support does have its limits.  Group settings work when everyone in the group has a similar background -- they do NOT work when some members of the group are different and feel ostracized.  This factor, I believe can trigger the resentments among women who did not fit the group.  Furthermore, there IS a place for EXPERT advice when there are complex situations that do not have clearcut solutions and even those complicated situations that demand stepwise changes over time.  ANY successful public health model for change ALWAYS has multiple avenues for affecting change.  We need to be able to assist those that are not reached by the group approach.

So, I would not stop at just "RN" versus "LLL".   I would look at the spectrum of hospital to clinic to home based as well as the spectrum from team based approaches (including psychological, nutritional, etc), single professional (medical only, psychological only) to lay approachs (peer support). 

Furthermore, I would look at the TYPES of problems for which these various approaches would work.

I think we have been entirely too simplistic in our outlook.  Clinging to notions that "peer support" works so its our salvation -- instead of looking at when or how that works or "banning the bags" without looking at how "informed consent" is going to be delivered will influence maternal attitudes.  My aha moment was when I was being interviewed for ReasonTV (I don't know if they ever aired the piece) about Mayor Bloomberg's so-called nanny state banning of formula.  We went around and around in circles with me patiently repeating no one is taking formula away and going back to all the ways women's choices were being taken away when formula was being given without fully informed consent -- we had a good laugh (the interviewer actually breastfed her kids to age two) about human milk in the grocery store -- but when I kept repeating how individual tailored advice SHOULD be given to women when they have problems that interfere with breastfeeding -- I knew this was the crux of our circular argument.  She and I both knew how that was SUPPOSED to happen, but she was assuming that women would be treated to the same sort of approach as the horrible film on baby shaking that women MUST watch before they escape the hospital and I was assuming an ideal of counseling that I'm not sure is viable in the current state of overstretched hospital staffing ratios that are present in many New York City hospitals.

I am also deeply disappointed on many levels and from various institutions and individuals who have argued against better more thorough education for those who deal with breastfeeding problems and that somehow we have a surfeit of overqualified professions.  Again, I go back to one of my original analogies.  I currently think we created a system whereby we have the equivalent of lots of hospital neonatologists who are trying to create systems where their work in the hospital will suffice for children all the way through adolescence OR peer support groups trying to handle everything from colds and disappointment because you missed the bus in the morning to treating invasive cancer and dealing with bipolar disorders.  And I'm sorry, but I am heartily sick and tired of everyone arguing against any sort of reasonable compensation for the care giving activities that nurture our society being ranked less than Joe the Plumber's ability to get rich by fixing your bathroom pipes.

Sincerely, 

Susan E. Burger

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