Friday, April 1, 2011

Thoughts on IBCLC training, reimbursement, and where the profession is headed

I don't remember when I first realized that the profession of "lactation consultant" existed. I must have encountered it at some point doing research for my undergrad senior thesis, which was (to make it very brief) a literature review and mixed-methods study on infant feeding decisions. The following year, when I did AmeriCorps, was my real introduction to the world of breastfeeding support: I did a 3-day training to become a Certified Breastfeeding Educator (taught by an IBCLC), began doing breastfeeding support in the clinics, and did some shadowing with in-hospital IBCLCs. That experience made me realize that I wanted to be an LC. One of my absolute favorite parts of the job was doing breastfeeding support, and I liked what I saw the LCs that I worked with getting to do. I enjoyed the one-on-one interaction, the clinical problem-solving, the feeling that you were working to help the mother achieve something that was important to her, and the satisfaction when something you suggested worked and - click! - for the first time, mom and baby had a successful feeding.

At the time, though, I looked into becoming an LC and couldn't imagine a way to get enough hours. At the time, IBLCE (the certifying organization for LCs) required thousands of hours of clinical practice to be eligible to sit the exam (for an interesting historical overview of IBCLC eligibility requirements, check out this presentation - opens as a PDF). When I was looking, the requirement was 2500 hours of clinical practice, which I would have to find a way to get independently (since apart from my one-year AmeriCorps term which was already over, I didn't have a job where I could get hours that would count towards my eligibility).

And I really considered how to make it happen. For years, I wanted to become an LC, and I would investigate ways to do it, and then I would give up again. And in this post I'm going to talk about why.

I've been putting off, mulling over, composing and revising this post for a long time. The seeds were sown when I first heard about the new requirements to sit the IBCLC exam, and when I read debates on Lactnet and other listservs; I've gotten e-mails and read other people's posts about this issue; but it's taken a while for me to figure out my thoughts about it.

The impetus to finally put this out there was sparked by some conversations I had at the Breastfeeding & Feminism conference with IBCLCs and IBCLC-wanna-bes. The wanna-bes talked with me about the difficulty of finding and funding training, the IBCLCs talked about their awareness of that difficulty, the limitations of the LC community in addressing the shortage of good training, and the issues with the current pathway system.

This is my current thinking and I'm very curious to hear what others think about it. I apologize for the length - it's quite possible it could be shorter and more succinct, but if I spend too much more time revising it will never get posted!

To start off, a little background about how you become an IBCLC: historically, there have been different pathways to qualifying to sit the exam. They have changed names and requirements more than once, but in my understanding they've all fallen under more or less two different routes:

1) Becoming an IBCLC already having some kind of medical/nursing/clinical degree. To qualify to sit the exam, these people have to have some lactation-specific education (although it is not standardized - hours from a vast array of providers and topics can count), and they also have to meet a minimum number of hours spent working with breastfeeding dyads. Importantly, these hours do not need to be under the direct supervision of an experienced IBCLC and can happen as part of the professional's regular work. So a nurse on a postpartum floor, a pediatrician, a dietitian at a WIC office - all of these people may be able to get their minimum hours through their work. (Pathway 1 in the current system.)

2) Becoming an IBCLC without having any kind of clinical degree. To qualify to sit the exam, these people have to also have lactation-specific education, and they need to meet a minimum hours requirement. However, their minimum hours need to be completed under the mentorship of one or more IBCLCs who have recertified at least once. (Pathway 3 in the current system.) These people can also do an educational program approved by IBLCE (Pathway 2), which provides the mentoring, hours, etc. all in one package, and requires somewhat fewer minimum hours, but those programs are few and far between.

Starting with those who will sit the exam in 2012, IBLCE is changing the requirements. From their information page on the upcoming changes:

IBLCE has identified eight subjects in which all first-time candidates must have completed the equivalent of one semester of higher education. These 8 higher education courses are:

* Biology
* Human Anatomy
* Human Physiology
* Infant and Child Growth and Development
* Nutrition
* Psychology or Counseling or Communication Skills
* Introduction to Research
* Sociology or Cultural Sensitivity or Cultural Anthropology

In addition, all first-time candidates must have completed continuing education in 6 subjects that health professionals typically will have studied as part of their professional training and/or are required for ongoing maintenance of their professional credentials. These 6 additional general education subjects are:

* Basic life support (e.g. CPR)
* Medical documentation
* Medical terminology
* Occupational safety, including security, for health professionals
* Professional ethics for health professionals (e.g. Code of Ethics)
* Universal safety precautions and infection control

The discussions I've seen online have covered a range of reactions. A lot of people are very upset about the new requirements. They argue that requiring all this essentially requires you to become an RN if you want to become an IBCLC (almost all of these are either required in nursing school or required prerequisites for nursing school). Some individuals from other countries have noted that there simply is no way for them to take these courses - they don't have community colleges or schools where you can just take a few credits here and there - unless they actually do enroll in a full-time academic program to become a nurse. Additionally, some people feel that lactation consulting is already becoming overmedicalized and is moving away from its unique roots in peer counseling, focus on empowering the mother, and in helping mothers find their own solutions vs. prescriptive "treatment", and this is accelerating that trend.

Other people are very supportive of the new requirements - even some people who came up through old, non-clinical pathways. They argue that if IBCLCs want to become respected as a clinical practice specialty, they need to have requirements that parallel other clinical degrees. MDs, RNs, OTs, PTs, etc. etc. - none of them begin practice, and most don't even begin their training, without taking basic courses in biology and anatomy, nor should they. An IBCLC who doesn't understand fundamentals of nutrition shouldn't be counseling a mother about appropriate complementary foods, and an IBCLC who can't read and communicate in medical terminology and documentation won't be respected by other clinical professionals that s/he is expected to work with.

IBLCE addressed some of these concerns directly in their FAQs page about the new requirements:

17. With these new requirements, it seems to me that IBLCE is discouraging those of us who are not health professionals from becoming IBCLCs. I know of several IBCLCs in my community who are not health professionals and they are well respected. Why has IBLCE placed so much focus on the new general education requirements?
IBLCE continues to support the long-standing practice of welcoming and encouraging practitioners, who are not health professionals, to prepare and become IBCLCs. The ability to actively listen and take the time to collaborate with mothers in developing an appropriate care plan and the dedication to supporting families beyond the early postpartum period are some of the well-developed competencies of candidates who are not health professionals.

As the lactation consultant profession has matured, it has become clear that it is necessary for all IBCLCs to be well-grounded in those subjects that are typically studied by health professionals. A strong foundation of knowledge in the health disciplines that are typically included in health profession curricula will position all IBCLCs to function as well-respected members of the maternal-child health team. In addition, employers and policy-makers will have increased confidence in the IBCLC credential. With this increased confidence in place, initiatives such as licensure, reimbursement and more jobs for IBCLCs are more likely to be successful.

22. I'm an experienced IBCLC and hold no other credential in the health professions. If I were not already certified, I would not be able to qualify for the 2012 exam without returning to school. This does not seem fair and it appears that IBLCE is discouraging non-health professionals from applying. Did the IBLCE Board take this concern into consideration before making the changes?
Yes. The IBLCE Board gave quite a bit of consideration to your particular concern. In fact, there are a number of Board and staff members who are IBCLCs that hold no other credential in the health professions. The IBLCE Board holds the mother support background in such high esteem that the IBLCE By-laws require that no less than 51% of Board members have experience in mother support leadership. In spite of concerns similar to yours being expressed, the consensus of opinion was that improving the quality of the IBCLC credential was of utmost importance. The Board voted overwhelmingly to support the changes.

I see both ways on the new requirements piece. Unfortunately there are a lot of LCs out there who don't know what they're doing. And unfortunately I don't think it has very much to do with their educational backgrounds.

The way I see it, there are bad LCs out there who have medical backgrounds and never bothered to do more than count up their contact hours with mothers/babies and study for the exam, without doing any training with other LCs to improve their skills/knowledge base. There are also bad LCs out there who don't have medical backgrounds and did their training without understanding important basics of anatomy, physiology, how to read research, etc. and who have never pushed themselves to improve their skills/knowledge. (There are also bad LCs out there who have great education/experience through whatever pathway and are just bad. There are also bad doctors, nurses, etc. etc. - being able to get through a rigorous educational program and pass a test does not, unfortunately, necessarily make you good at your profession. Sigh.)

But I believe that all the challenges these new requirements pose for IBCLCs-in-training - in the U.S. at least - have less to do with the requirements themselves, and more to do with the educational pathways available. And in the end, it all comes inevitably back to licensure and reimbursement. How? Let me explain:

It may be standard and reasonable for RNs, MDs, PTs, etc. etc. to have these courses as prerequisites or as part of their professional education. However, they are generally not expected to come up with the entirety of their professional education on their own. They have educational programs which provide at least some of their educational requirements, along with things like student loans, work-study positions, fellowships, or other structured financial assistance that helps students get through their education without having to pay for it all up-front, out-of-pocket.

This is not true of IBCLCs-in-training. Along with all of these distribution requirements, they need to pay for 90 hours of IBLCE-certified lactation education (under the old requirements 45 hours). This education - which can be conferences, online courses, in-person workshops, etc. - is not cheap. Finally, they often have to pay private IBCLCs for mentorship (if they can even find one – frequently a very challenging undertaking, one of the main reasons being that the private LC is essentially training her own competition). Understandably, mentor IBCLCs need to be compensated for the extra time and effort they put in for teaching. This is another chunk of change.

When you look at all that, you are looking at a significant amount of $$$ to become an LC. (You are also looking at the exact reason that even though becoming an LC was my dream from the moment I met one, I never did it on my own. We'll get back to this in a moment.)

There are a very small number of IBLCE approved educational courses that provide a really standardized, all-in-one education the way a medical or nursing school does: you get your clinical education and your clinical rotations in a package. If they're through an accredited institution, you might even be able to get student loans to help pay for it.

This type of program was how I managed to finally get IBCLC training, because one happened to get started at my school while I happened to be there. This is why I was so excited and honestly in awe of the fact that I was getting to become an IBCLC. Why was it so amazing to me? Why did I hold off pursuing this dream?

And this is where we get back to licensure and reimbursement. (I know this is U.S.-centric, but the U.S. has a pretty large percentage of LCs and I think that LCs face this issue to varying degrees around the world. It's also one of IBLCE's justifications for changing the requirements.) Many people who look at the new requirements have said something along the lines of "Then I might as well go ahead and become a nurse". Why would they say that if they want to become LCs? Because nurses get paid. Nurses are part of standard care in a hundred different practice settings, they are licensed, and what they do is reimbursable through insurance. This is among the reasons that non-RN IBCLCs are not generally hired by hospitals, pediatric practices, etc. and among the reasons that private practice IBCLCs have trouble making a living. (The US Lactation Consultants Association has an excellent white paper on reimbursement - particularly relevant are pages 14-15).

There was no way I could justify, to myself, sinking thousands of dollars into an education that would take years and lead to a profession that could probably never be my sole source of financial support. I most definitely couldn't justify paying out-of-pocket for all that education or figure out a way to do it without decimating my future financial health and again - for what?

I think that the solution to all of these problems - training, education, experience, or lack thereof - is to have more standardized educational programs available through accredited schools. But I imagine schools, if/when they consider offering IBCLC training programs, will have financial concerns similar to the ones I had when contemplating the certification. Will they really have enough students willing to pay the amount of money needed to sustain those programs, now that these programs are about to get a lot more expensive?

The bottom line to me: you can get people to pay for years of nursing school, med school, etc. because they know they can pay back those loans eventually, and support themselves. The same promise is not there with LC work and until it is, more and more stringent educational requirements make it harder and harder for people to get into the profession without having some other professional credential that will get them reimbursed fairly for their work. An MPH student (not an RN) asked me at the conference whether I would recommend her doing the IBCLC course next year and because the cost of it has risen so much since I took it, I honestly couldn't give her a strong "yes" unless she is willing to commit to a life of private practice. She pointed out that I have a hospital position, but I assured her that I got it basically through sheer luck and those positions are few and far between.

I get that IBLCE is aiming for that eventuality of licensure and reimbursement and that they're hoping that changing the requirements will be a step in that direction. They say as much in the FAQs:

15. These new requirements will make becoming an IBCLC even more expensive. Are the IBLCE Board members concerned that the new requirements will reduce the number of applicants who are eligible to become IBCLCs?
The new requirements may result in a decreased number of exam candidates in the short term. However, the reason for making these changes is to increase the value of IBCLC certification. The IBLCE vision for the IBCLC credential is to "increase the number and improve the quality of IBCLCs."

IBLCE is the global authority in lactation consultant certification and raising the educational standards for the lactation consultant profession is crucial to the future growth and value of the IBCLC credential. While there may be a short-term drop in the number of prospective IBCLCs, the increased value of the credential will make IBCLC certification more highly desired by not only first-time candidates but also by recertifying IBCLCs.

But what’s not really acknowledged here is that a profession that was already fairly inaccessible without great financial privilege will now be almost totally inaccessible. A lot of IBCLCs have said to me, "Oh, we're so glad to see you! We see so much gray hair at LC conferences, we need young people in the profession!" But young people can't afford to go into the profession, to say nothing of other groups that may have greater financial and family struggles. I go to LC conferences and see almost all white faces. IBLCE acknowledges that fewer people may sit the exam under the new requirements, and they promise a future pay-off. But how far into the future?

So that's what I'm thinking right now. And one final slight tangent: the other thing that writing this post has made me realize really bothers me is the current requirement for practice hours for clinical professionals. I think the need for all this RN-like training especially digs at some people because those who come through non-clinical pathways train for hundreds - and, under previous pathways, sometimes thousands - of hours under experienced LCs (and paid for those hours). However, RNs get to count up hours they spend as part of their jobs - no LC supervision necessary - and then take the exam. I’m not saying this experience is not valuable, but we don’t say to nurses “Hey, you do a lot of things that are related to what doctors do – pass the medical boards and you can practice medicine!” And IBCLCs spend a lot of time talking through anxieties and emotions with their clients, but can’t just count up those hours, take an exam, and become licensed as therapists.

Let me clarify here that I am NOT saying that all, or even most, RN IBCLCs are unqualified! I have gotten my training almost exclusively from RN IBCLCs who I respect profoundly and are fantastic LCs. Several of them have, however, told me how lucky I am to be able to mentor with LCs because when they got their certification they had never worked with another LC and had to learn on their own a lot of what they're teaching me now. To my mind, if non-clinical professionals are now being asked to spend time and money getting the coursework that the clinical people already have, the clinical professionals should be required to spend the time and money on finding and using direct LC mentorship. I think that would be at least as big a step towards improving the quality of the profession as these new requirements.

And that's my more-than-two-cents! Other thoughts out there? Especially from prospective IBCLCs?


Supurrkitten said...

I live in an area where there is limited opprotunity to gain the clinical hours needed to sit for the IBCLC and I am an RN, who happens not to work with lactating moms. I have wanted to become an IBCLC for approx 3 years and am stumped on how to get started. I have attended conferences and read books, but real mom time is limited to internet and friend group and absolutely no mentoring. I feel you. It is like looking for the golden egg to become properly educated. I am equally frustrated.

Arual said...

This is definitely going to cut out a lot of less independently wealthy applicants.

Their hope may be to make it so that an IBCLC is a reimbursable position, but the changes they have made make it seem like we need to come up with an alternative lactation consultant position so that there is SOME way for women to get in and help other women without selling off their personal possessions and giving up their lives. Peer counselors are a start, I suppose.

Susan said...

I, too, have looked into the LC route since I figure it would be hugely beneficial as a doula to have that additional experience, and I, too, have been put off of it for these same reasons - no money, not a lot of opportunity to gain experience, etc. I probably will end up becoming an RN first and then tacking things like this onto it for exactly the reasons you've stated here. I have no desire to be a nurse, but I'd like to be a midwife, IBCLC, etc, and nursing just seems the best jump-off point for all of that. *sigh* It's really frustrating how tough this all this, but at the same time, like you, I can see both sides. It would be nice if this were more accessible, though.

Tatiana said...

This change came at an optimal time for me. I have completed many of the requirements in my education already, and while I don't need the A & P and some others in the short term, I will in the long term and really want them so am delighted for the external impetus. I'm already accruing debt for a BS and hopefully MPH in the future, so the handful of additional courses doesn't change my outlook considerably. Plus we don't have mobile LCs in my area so I know that a private practice (partial pro bono, of course) can be part of the mosaic of my future work life. For me integrating the requirements with a broader education and integrating the work with other avenues is what is making it seem feasible and appropriate to me. I can't see how I could do it if it was my only activity - either the education or making a living.

Rebecca said...

@Supurrkitten - So many people encounter these same issues! I talk to them often. Without formal educational programs to provide clinical hours they are very hard to find.

@Arual - I feel you on needing an affordable way to become an IBCLC, but I already see a number of issues with the current affordable "alternate" routes that people take. It is so easy for consumers to get confused between CLCs, CLEs, CBEs, etc. etc. and not understand that those people have usually (at most) 5 days of formal education. I'm not saying that you can't find some fantastic, experienced CLCs out there but when we start muddying the waters with alternative credentials it makes it harder for the sleep-deprived new mother to distinguish what a truly qualified professional is, and for people who may honestly mean the best - to "get in and help other women" - to overrepresent their credentials and get in over their heads. (AKA "a little knowledge can be a dangerous thing"... I have been guilty of this myself.) I would like to make the IBCLC credential more accessible vs. adding more to the alphabet soup.

@Susan - It is a really big upfront investment. If for now you'd like to add more breastfeeding support skills to your doula practice, though, you could consider taking some of the LC education offered online, and/or asking an LC if you could shadow her occasionally - not for credit or for a fee, just to pick up some more knowledge and know when/how to refer. I also think doulas do a huge amount for breastfeeding just by being there and being supportive!

@Tatiana - I'm glad to hear that some people are OK with this change and are able to keep moving forward! When do you plan to sit the exam? Good luck!

Anonymous said...

I am wondering the impact this would have from an equities perspective. I know it's addressed in a PowerPoint at there site, but how do you get people from under breastfeeding communities to become LC's when the stakes are now so high it puts the opportunity out of their grasp? Midwifery has the CPM route which addresses alternatives to CNM licensing and perhaps this should have more options as well. I'm just concerned that women from lower SES will be discouraged and LC will lack diversity.

Jen said...

Thank you so much for writing this. As a SAHM trying to figure out a new career (that I need to make a decent amount of money at) and a newly accredited LLL Leader, becoming an IBCLC seemed like a perfect fit for me. I need to pay my first college bill in 2 days, and before I did that I wanted to do (more) research. This post was eye opening to me in many ways, and validated many of the concerns I have. I am very unsure of where to go from here. I appreciate you taking the time to write out your thoughts on this topic.

Anonymous said...

Six years ago I decided I wanted to become an IBCLC. I was sitting nursing my daughter thinking about my new direction in life. No longer working in international banking and being a SAHM. I loved the lc that helped me in the early days of Breastfeeding. I was steered wrong by multiple pediatricians, home care nurses and family advice. My lc (non medical background) was the one person to steer me in the right direction.
I began to become a league leader over a year long period. I started a group in a part of town that was under served. I also began working as a volunteer with teenage mothers. Thinking I needed 2500 hours. I took the 45 hour course. I was ready to register for the exam when I found out I was expecting. I decided to wait since there was a baby coming and it was not a good time to return to work. My baby died half way through the pregnancy. A month after his death I was picking up the pieces and trying to pick up where I left off. I then learned the qualifications standards had changed and that I was no longer qualified. The IBCLCE referred to this as an unfortunate incident but was indifferent. I have wasted years of my life pursueing a moving target. If I must go back to school at a great expense I will get a masters instead. Breastfeeding is not a a disease. Women succeeded without medical professionals. Just as birth was taken from midwives and given to OB's lactation support is being taken from the peer counselor and handed to health care professionals. Is this what the average mom and baby need?

Anonymous said...

With all the experience on this feed, do you know of a class/ course to cover the universal safety precautions and infection control requirement?

Rebecca said...

Nope, although I suspect sites like Health e-Learning will start offering them. I suggest you ask on Lactnet!

Anonymous said...

Thank you. I have posted

Leaf in the wind said...

I found this website to help anonymous. it has 5 of the 6 she was looking for. (Or anyone else)

Fondly, Jenn said...

As a RN,BSN,IBCLC currently in Graduate School to become a WHNP I have to state that my belief is that the more education IBCLE requires will only increase the standard of care breastfeeding mother's receive. I currently practice in a hospital setting and it is my belief that all IBCLC's have some type of medical backround and preferably at least RN backround. This would assure a certain standard of care to lactating clients. There are other ways to support mother's via LaLeche League and/or Certification programs to teach. As far as treatment goes I believe medical professional involvement is necessary by a qualified individual. I feel so strong;y about this that I am furthering my education in order to treat better and inable myself to write proper prescriptions for lactating women. I am proud that IBCLE is really looking at IBCLC as a medical profession, increasing its standard to provide best care to lactating mother's. I wish you the best of luck becoming an IBCLC and I agree that you might as well go to nursing school and/or medical school as this is where this profession is headed. This is great for lacatation promotion and I feel proud to be able to be part of such a valuable profession!

Anonymous said...

I am enrolled in my communiy college currently, which, unfortunately, does not offer two of my required general education courses, Nutrition and Research. Does anyone know of a program where I can enroll in these two general courses, plus my 6 continuing courses? I am interested in LER (, as someone posted above, but would rather save myself from enrolling in two programs, if possible.

Anonymous said...

I am enrolled in my communiy college currently, which, unfortunately, does not offer two of my required general education courses, Nutrition and Research. Does anyone know of a program where I can enroll in these two general courses, plus my 6 continuing courses? I am interested in LER (, as someone posted above, but would rather save myself from enrolling in two programs, if possible.