Lactation Consultants: the Midwives of Breastfeeding

By Chris Mulford, RN, IBCLC

I believe that LCs are like the midwives of breastfeeding. We are advocates for breastfeeding (the process), and for the mothers, babies and families that breastfeed. An LC knows a lot about the process and the people. A good LC also realizes there is a whole lot more that he or she doesn't know.

What is breastfeeding?

• It is a physiological process which is part of reproduction. So LCs need to know a lot of health-care-related stuff.
• It is a family relationship, so LCs need to know a lot about humans, cultures, human development, families, their legal status, rights, etc.
• It is an economic activity, so LCs need to know about domestic (household) economy and national economy. We need to understand the politics---the status of women and children, and how breastfeeding fits in with other work women need to do.
• It is a productive activity, so LCs need to understand the "product," the fantastic foodstuff called human milk, and its nutritive, protective, and curative properties. We need to understand how milk can be threatened by pollution and chemical exposure. We need to have "kitchen" and "bench" knowledge about expresed milk as a food, as a medium for bacterial growth, and as a subject of scientific inquiry.
• It is a "woman" thing, so LCs need to understand women's culture, and women's politics, and women's history---and these are different things in different cultures around the world.
• It is beautiful and spiritual---so it's nice if LCs can describe and teach and enable breastfeeding in a way that respects its beauty and its spirituality.
• And once we know some of these things, LCs have to be teachers and advocates in order to present this knowledge to all the people who don't know as much as we do.

Now, suppose you're a person who needs some "breastfeeding work" done---teaching doctors about breastfeeding; helping the mom of a premie; testifying in a custody case involving a nursing baby; advocating for a lactating woman at her workplace; designing a breastfeeding promotion program; drawing up a law to protect breastfeeding in public places; writing a pamphlet for pregnant teens. You don't have the knowledge to do these things, and you want to hire somebody who does. How do you do it?

If there's a profession called "lactation consultant," and members of the profession are supposed to be able to do these kinds of breastfeeding work, then you as a buyer of services have some protection, some assurance that you'll be getting the expertise you're paying for when you consult an LC. And if there's no such profession, then you as a buyer will have a harder time finding what you need---and you just may decide it's not worth looking for what you need. So in the end the people who need breastfeeding work just won't get it done.

In the U.S. there are three kinds of credentialing process to give some assurance to buyers that professionals are competent. They are licensing, registration, and certifying. Licensing is the most restrictive; certifying the least restrictive. This is one reason that the IBLCE was set up to *certify* LCs. Because people come to the field from so many different backgrounds, it was designed to be inclusive, not exclusive. They didn't want only health care workers to be LCs.

But this inclusiveness leaves us vulnerable too. Anybody who can claim a lot of hours working with mothers and babies, take some CE courses (and just sitting at a lecture is sufficient; you don't have to prove you learned anything), get a couple of recommendations, plunk down some $$, and pass a written exam can be an IBCLC. This takes a lot of work, and the great majority of IBCLCs take the process very seriously and work hard at learning what they need to know. But in my opinion, passing the exam doesn't really prove that you know how to be an effective LC.

Even if the buyer has the protection of some kind of credentialing of the professional, the buyer is still well-advised to check things out. You ask the candidate for their C.V.; you interview her; you get references; you look at their other work. Of course, if you're an engorged mother with a jaundiced baby, you may not have the time or energy to be picky. If you live in a remote area, you may not have any choice---you're lucky if there's ONE person who can try to help you. And the work you need done will dictate to some extent the kind of LC expertise you need---writing, teaching, research, designing, administering, advocacy...all of these might require different skills from the clinical skills that a mother and baby with a problem would need.

So as our profession comes of age, we have to keep working over the same ground, looking at questions like, "How does a person become an LC? How can we be sure that LCs are competent? ethical? How can we be sure that LCs stay current in the field?" I doubt that there's ONE right way to accomplish these ends. A professional organization---ILCA---is one good way. A high-quality journal---JHL---is another. Networking---meetings, Lactnet, local coalitions---is another. Supporting and improving the certifying process. Setting up pre-service education programs as well as continuing education programs. Some kind of internal "self-regulation" to keep ourselves and our colleagues up to standard. And some kind of standards....which is where I began this discussion.

During the years (most of my adult life!) that I've been involved in what I think of as "the Breastfeeding World," I've been concerned about something I might call our "validity," our truth. I feel as if we (at least in the USA) have been marginalised---or closeted---and our issue has been left out, overlooked, forgotten---for so long, and our struggle has been so hard, that we're in danger of developing a skewed view of reality. You know that feeling of identity, instant understanding, acceptance that you experience when you find another lactation "nut"! "Oh, good, here's somebody I don't have to explain everything to---she (or sometimes it's even a 'he') already understands about breastfeeding." It feels so comfortable to be with other people who see things through the same "breastfeeding glasses" that we do.

And because of that feeling, I believe that we have to be extra careful, extra watchful, to be sure that there's some objective corroboration for our perceptions. A peer review process is what I'm getting at, I think. We have to help each other identify deficiencies in our understanding, our presentation, or our goals and strategies. We need standards that define LCs---who we are, what we do. If we don't do this for each other, surely our critics will, and they won't be kind!

The rigor of the research process is one standard our profession can cherish. Another standard is a clear position on the ethics of breastfeeding supplies, equipment, infant feeding paraphernalia, and corporate sponsorship. Others might be cooperation among breastfeeding advocates of all kinds....Justice and fairness in dealing with our colleagues....A global rather than a local viewpoint....Accountability in clinical practice. And I'm sure there are others. ILCA drew up Standards of Practice about 5 years ago. That's a start.

If we're a profession, we need to act like one. And if we're not a profession, we need to decide what we ARE.

Peace.

Chris

June 1998.