Friday, May 25, 2012

IBCLC vs CLC - which is better? Why are we asking?

Emily at Anthro Doula just completed her Certified Lactation Counselor (CLC) course (congratulations!) and in her post on what she learned, she pointed to a link to a position paper by the organization that runs CLC training, Healthy Children. The position paper essentially argues that the CLC and IBCLC are equal credentials and that there is no "hierarchy" in lactation credentialing. I have seen this as a hotly discussed topic among IBCLCs, CLCs, and doulas recently - online and in person - and reading the position paper made me really want to get my thoughts down on this.

There are a lot of arguments about which training/exam/experience turns out better lactation professionals, or whether one is guaranteed to turn out better professionals that the other. There are CLCs out there arguing that CLCs can be just as qualified as IBCLCs to help breastfeeding moms. There are IBCLCs who argue that the training and credentials of IBCLCs are superior and that mothers should not count on CLCs for certain kind of breastfeeding help. The comments sections of the second post engages in some debate, so read up if you want to familiarize yourself with some arguments on either side.

On the question of who is the more advanced support for breastfeeding and who receives the more advanced training, my answer is unequivocally IBCLCs. I did a training very, very similar to the CLC training when I was training as a doula. It was a slightly shorter course, but otherwise it had many of the features that the CLC's position paper favorably compares to IBCLC training - competencies testing, written exam, dozens of hours of classroom teaching, etc. It was a FANTASTIC training! I learned so much, and still use some of the skills I learned there today. I went on to help a lot of mothers and babies breastfeed; I think I did about 40 hands-on consults in the following year. I had what some CLCs feel makes them comparable to IBCLCs: training and experience. I puttered along happily with that training for years, feeling capable of handling a lot of breastfeeding questions.

Then I did IBCLC training. I am here to tell you that there is no comparison between a CLC-level course, and a Pathway 2 IBCLC course. How can there be, when in Pathway 2 you spend hundreds of hours hands-on with a clinical mentor? There was so much I learned from my mentors, a lot of mistakes I made that they were able to correct, and a lot of time to soak up knowledge and techniques. Could I have gotten there on my own by trial and error, via experience as a green CLC? Probably - I had to make some mistakes on my own anyway when my training was over, because making mistakes is an inevitable part of learning, in any profession. But let me point out that when we make mistakes to get experience, we are making them by working with mothers and babies who may have more difficulty breastfeeding, health issues, and emotional pain because of our mistakes. Shouldn't we do our best to minimize the number and impact of these errors by setting up mentor relationships, much as other health professions like medicine, midwifery, and nursing do for their trainees and new graduates?

(The one place where the CLC might get traction with me in this argument is in the issue of Pathway 1, which I have also written about before. I think this is an area that IBLCE will need to address in the near future - the fact that individuals with another clinical degree do NOT need mentored hours - although they do have many hours of hands-on experience. I think it's problematic that someone with no other qualifications can become a CLC without ever doing hands-on clinical work and then promote their services. I think it's also very problematic that someone with clinical qualifications can become an IBCLC without ever MEETING another IBCLC. Those IBCLCs are missing out the same thing that a CLC is - mentorship and hands-on training.)

So no, I don't think Healthy Children, or CLCs - especially new CLCs - should say that IBCLCs and CLCs have equal experience and training to offer to mothers. Does this mean that if I took the best CLC in the world and compared her to the worst IBCLC, that individual IBCLC would still be better? Probably not. As this post points out, there are some really bad IBCLCs out there, and great CLCs. There are likely also CPMs out there who give better, more evidence-based counseling and treatment to their clients for gestational diabetes than do some OBs, even though OBs are supposed to be the experts in high-risk pregnancy. Anybody can be good or bad at something, regardless of the letters next to their name. But I will certainly argue that the overall average experience and range of IBCLCs exceeds that of CLCs, and I base this in large part on the fact that I've done both kinds of training and lived the difference. There is no way that new CLCs can handle 95% of breastfeeding problems and that the rest require advanced, non-lactation interdisciplinary support as this post claims - I can't handle every breastfeeding problem without calling on more experienced IBCLCs for help and guidance, and I've already been an IBCLC for two years (and no, it doesn't need to rise to the level of needing outside specialties to need some extra guidance.) In fact, I felt MORE confident and independent BEFORE I did the IBCLC training - because I didn't know what I didn't know.

BUT - until we get IBCLC licensing in the U.S. (which I am excited about and seems to be moving forward on many fronts) the question is to some extent academic. Anyone can advertise their services, and any CLC can say she's equal to an IBCLC without legal repercussions. The debate is mostly lactation-world infighting and it's questionable whether, apart from potentially convincing CLCs not to advertise their services, it will really benefit consumers (unless there are a lot of sleep-deprived new mothers out there researching the issue on the internet before they decide whom to hire). I think the more interesting issue raised here is access. I've written about how financially and logistically impossible IBCLC training is for many people to attain. People who get bitten by the breastfeeding bug fall hard - I know, I got bitten myself. You end up searching and searching for ways to do what you love - helping moms and babies - and all the routes to an IBCLC seem closed. I would brainstorm ways to make it work at various points in my life, before giving up again upon realizing there was no way I could get the clinical hours. The CLC, on the other hand, has brilliantly positioned itself as a way to be "like an IBCLC" without all the impossible requirements, not to mention the financial investment in IBCLC training that is so difficult to recoup. It is unleashing a group of people who so deeply want to do this work by giving them a credential they can feel is "close enough" to enable them to pursue that passion. Should we be surprised that CLCs are such vocal defenders of the certification, that Healthy Children is investing so much in legitimizing it, or that people sign up in droves?

But it is troubling to me, because what we need is not to make a lactation consulting credential that is more accessible because it's quicker and cheaper. We need to make a credential that is accessible because lactation consulting becomes a profession that will pay off in the long run through reimbursement and greater recognition, and because it is offered through formal educational programs. This would enable the credential to become more rigorous, not less, which I believe is the way the field needs to go.

In short, I think in a better world, we wouldn't be asking which is better, IBCLC or CLC. No one would be battling to prove that they could do consults with a CLC credential, because the people who wanted to do consults would be able to become IBCLCs. The CLCs could happily go on doing basic breastfeeding support, education, etc. - which is a great role for that credential to play.

Thoughts? Any IBCLCs and/or CLCs out there want to give their perspectives?

16 comments:

Elita said...

I'm a CLC and while I enjoyed the class and recommend it, Healthy Children is full of shit. They don't even believe their own position paper. If there is no difference, why do they require an IBCLC to teach the CLC course? I'll wait....

Cradlehold said...

I went through the CLC course as a segway to IBCLC. There is no way that it compares to the HANDS ON training I received and the thousands of hours working with breastfeeding moms that I had to prove in order to take my exam. I often compare it to the nurse's aides vs registered nurses. Both can do bedside care but who would you want to administer your IVs or bloods? Thought so.

Rebecca said...

@Elita: One of the posts I linked to seemed to imply that they don't necessarily require an IBCLC to teach the CLC course - do you know if that's true? If so, it does seem like they're contradicting themselves. Of course, all they would have to do is to have some CLCs start teaching the classes and say "Nope, it's OK for CLCs to teach each other."

@Cradlehold: That's a good comparison! I think it's interesting that both my commenters so far have also taken a CLC course and don't agree with Healthy Children. Why do you think some CLCs do?

Elizabeth said...

Thoughtful piece -- thank you. I agree: (1) much of the sturm und drang is in-fighting by lactation professionals, precisely because we *do* know the significant differences in education and clinical training between IBCLCs, and the alphabet soup of other BF helpers out there; (2) licensure in the USA will be an effective means of having IBCLC services recognized as appropriate for reimbursement, both for the hospitals who hire IBCLCs and provide their services, and the mothers who have health insurance policies covering in-and out-patient IBCLC care -- but it is a long, slogging political process that has to be played out state by state; (3) the IBCLC profession is only 26 years old. Heck -- the WHO Code is older. It ought not to surprise us that we are still, very much, in the process of having to educate "the market" (mothers, public health administrators, policy makers) about who we are and what we do. My favorite position paper about the IBCLC role is written by ILCA and may be freely accessed here: http://www.ilca.org/files/resources/ilca_publications/Role%20%20Impact%20of%20the%20IBCLC-webFINAL_08-15-11.pdf

Queen Bee said...

I also began as a CLC and WIC Breastfeeding Peer Helper before becoming IBCLC. In my CLC training, the instructors themselves were IBCLCs and made VERY clear the distinction between CLC and IBCLC and varying scopes of practice. It was drilled over and over again that in some cases, a CLC would have to yield and refer on to an IBCLC. I personally had no qualms in doing so and worked directly under an IBCLC in WIC.

I do know that in our state (Ohio), there are areas with no easily accessible IBCLC and in those areas, the CLC certification has taken off, which is not necessarily a bad thing. I am NOT comfortable with someone with less experience, education, and training taking on more than they can chew...

ThatRedheadMom said...

I am neither a CLC or an IBCLC. I am just now starting to get into the Birth & Breastfeeding proffessional world. While my ultimate goal is CNM, my children are still too small for me to devote myself to school (due in Aug with 3rd/final baby).

So, to 'get my feet wet,' I am pursuing DONA doula certification (workshop is in November) and CLE through CAPPA.

It is QUITE obvious to a novice such as myself that LC's do not compare to IBCLC's (I've looked at the overwhelming training requirements! I'll leave that til after I complete my CNM program!)

It's impossible to put in half (or less than) training into something and yeild the same results. I agree where you said you can be good, or bad at something, regardless of the credentials next to your name. But, the amount of hands-on, practical experience you attain while pursuing IBCLC exceeds even the best CLC training. Even a layperson such as myself can see that.

PS. IBCLC attainment is SERIOUSLY intimidating!

Veronica said...

I've had to think about my comment since I read this yesterday. So here's what I've come up with:

I am a CLC, and I have been for 4 years. I'm also a birth doula, a Lamaze educator, and a child passenger safety technician. I was a doula first, and educator second, and a CLC third. When I did my training, out of 50 people in the room, I was the ONLY one who wasn't a nurse or a doctor. The most recent training in my town was again mostly nurses and doctors, but with a smattering of doulas and educators (I've heard 8 or so). What your argument COMPLETELY ignores is that in my case (and I'd argue the majority of cases), those of us who are CLCs do work extensively with breastfeeding moms, albeit outside of the hospitals. So to say that a CLC has no hands-on experience is a false argument. It's not required, but it's probably the truth for the majority of us.

And in my case, I have about 400 hours that would count in ILCA's eyes as hands-on experience. But I don't even know if I even want to work towards becoming an IBCLC. I lost piles of respect for the organization now that they lowered their ethical standards and allow IBCLCs to shill for bottle companies. Not to mention ILCA keeps making it harder for anyone who isn't a nurse to become an IBCLC. The requirements on how we get hands-on time are impossible for a lot of people to obtain. Hospitals here won't let people shadow the IBCLCs unless you already work there. I don't think ILCA really wants there to be more IBCLCs (despite the lack of resources in this large metropolitan area for all the moms who need help), and if they do, they want the bar to be super high. They aren't making it easier, they are making it harder.

What I will say is that, as a CLC, I have a lot of the basic skills (and yes, experience with moms, too) to help with the vast majority of breastfeeding issues. But we don't get training on nipple shields (not enough, at least), or SNS systems, how to manage poor weight gain, etc....and in my training, at least, they emphasized that. And yes, I'll admit there are newly-minted CLCs that really have no business helping moms the way they are yet. HOWEVER...I am tired of REALLY bad IBCLCs. There are so many who are handing out nipple shields for sore nipples, but not having moms apply them correctly, not telling them to pump, not having babies come in for weight checks.....really awful stuff. And that's another thing. ILCA is doing a really poor job of keeping the IBCLCs up to date. I have ONE (ONE!!!!) good IBCLC that I refer to. The rest lack any real skills to helps moms beyond handing them a pump or a nipple shield, and that's just a joke.

In my case, I'm hoping to do the 2nd 45 hour training and become an ALC. And then, yes, I'll feel pretty comfortable with almost everything...except maybe NICU stuff, which is just fine. I don't know why I'd be there, anyway.

Rebecca said...

@Elizabeth: I think that's a good way of putting it...often people seem to be scolding lactation professionals for "infighting" but who else is going to discuss this, if not us? I keep trying to remind myself that the profession is young and that these are normal growing pains, even though I want the evolution of the IBCLC to be sped way, way up!

Rebecca said...

@QueenBee: I'm glad to hear that the CLCs in your training got a good sense of their scope! I think it's very illustrative of my point that CLCs are taking off where there's no IBCLC, because people are turning to their only option for lactation training. Do you feel that those CLCs are biting off more than they can chew?

@RedheadMom: Good luck with your doula and CLE training! I agree that the requirements for CLC and IBCLC are very different in terms of the amount of time spent on the training. The IBCLC training is intimidating but I think it would be wonderful if we had more CNM IBCLCs!

Rebecca said...

@Veronica: Thanks for your comment. I wanted to clarify this:

"those of us who are CLCs do work extensively with breastfeeding moms, albeit outside of the hospitals. So to say that a CLC has no hands-on experience is a false argument. It's not required, but it's probably the truth for the majority of us."

I am not saying that people taking the CLC course don't work hands-on with breastfeeding moms - but it ISN'T required, nor is it standardized, nor is it mentored. I helped my doula clients latch their babies, and taught classes about breastfeeding, but it was very different from doing in-depth consults.

I also just wanted to correct your statement about ILCA - ILCA is the International Lactation Consultants Association, a professional group - IBLCE is the organization setting the ethics code, exam requirements, etc.

And your statement about IBLCE not wanting there to be more IBCLCs is an interesting one. I hope and believe that IBLCE does want more IBCLCs, but I am concerned that many of the changes in educational requirements are happening without any work to increase access to IBCLC education/training. I don't think there's anything wrong with the bar being high - we should have high standards for the profession - but you have to have ways for people to get over the bar. The hands-on time IS almost impossible to gain and the new requirements for academic courses are really increasing people's financial investment. I don't believe IBLCE is deliberately keeping the numbers of IBCLCs down, but neither are they focusing on the growth of the profession.

I am also tired of bad IBCLCs...although I don't know that it is necessarily a fault of IBLCE not keeping IBCLCs "up to date" since IBCLCs are required to recertify every 5 years via continuing education or exam. To me it's a more complex issue, including the fact that there are bad apples/practice variations in every profession, but also that different Pathways involve different amounts of clinical training, that there are very limited evidence-based guidelines for a lot of breastfeeding issues, and that there is often limited opportunity for clinicians to spend time practicing together and improve their skills. But they are the reason I want the bar to be raised...not lowered. I'm sorry to hear you have so few good IBCLCs in your area!

I was curious about the ALC course after you referenced it so I looked at the description on Healthy Children's website. I'm puzzled as to exactly what it covers, besides counseling strategies (which are great!) and case studies. I was expecting it to cover specific topics such as nipple shields, slow weight gain, tongue tie etc. but those don't seem to be part of the competencies. Is there something about it I'm not seeing?

Arual said...

My first and only experience with an IBCLC left me jaded about the credential. I received poor advice, was handed a nipple shield with no real training or mention of the potential pitfalls of its use, and sent home. She called afterwards to tell me that my one-ounce-past-birth-weight-at-2-weeks child was "underweight." It scared the hell out of me until someone else (a WIC breastfeeding peer counselor) told me that was wrong, and that in fact I was OVER FEEDING him (5 ounces, I gave him whatever I pumped, not knowing it was too much). Maybe its that she worked for the hospital. Maybe I caught her on a bad day. All I know is, I received much better help from someone who supposedly has far less training, and I will never place my faith in someone purely because they have a certain credential again.

I hope I run into some better examples of IBCLCs as I begin working towards learning more about helping other women with breastfeeding.

Veronica said...

@Rebecca-
I stand corrected on the ILCA/ IBCLE confusion. Just replace one for the other.

I mean, yes, there are CLCs who take off way more than they can chew but I don't think it's at the direction on Healthy Children. I'm in a community that likes to push the boundaries of what's ok for a doula todo all the time, so they really don't care what a CLC "should" do. I even know a few people who called themselves a CLC without taking the Healthy Children training. And locally, I know of a few CLCs who set up shop who really have little business to do so, and I worry for those families that go to them for help.

However, it's hard not to think IBCLE is trying to purposely make it harder and have fewer people qualify. I have watched the requirements change more than once in the last 7 years, I think. It's more expensive and it's harder for a layperson to become and IBCLC, which makes things worse, not better, if the goal is to increase access to IBCLCs.

As far as the ALC course, it has to be somewhere closer to me than Hawaii before I can consider it. And if nothing else, it's the second half of the new 90 hour requirement from IBCLE, so.....there's that. And, I should also point out, they require that you also take a course on maternal/infant assessment along with the 45 hour training. Until then, I'll keep up with what I do, working with mamas, but refer to the good IBCLCs when things become more challenging than I should handle.

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Emily said...

Hey Rebecca! Thanks for the shout out :) I am just catching up on blogs so I am very behind.

I have already heard stories of women (namely nurses) in my area giving bad advice and saying that they learned it at the CLC class. It's really too short of a time for people to really learn, and many people have selective hearing... And a LOT of people in my training were lay people, not people who have gone through post-secondary or any clinical education. So that's a real shame.

I also think it's a shame that it is getting harder for people to become IBCLC's. I think we need a lot MORE IBCLCs, not fewer, and I think a lot of people would make great IBCLCs despite never having attending nursing school, etc.

I think CLC's can fulfill a great role, such as breastfeeding peer support group leaders, additional training for doulas, and so forth, but I definitely do not think they are at an equal level as IBCLCs, and should not be hired for the same roles. I know IBCLCs personally, and I know where is so much more to the training and the profession than meets the eye.

Great discussion!

Rebecca said...

@Veronica: It sounds like you realize that there are some boundaries that shouldn't be crossed, but that others don't - and as you point out anyone can say they are a CLC - or even an IBCLC for that matter - until we have licensing that will remain the case. I think the argument though that "Getting an IBCLC is too hard so we should be happy with everyone getting CLCs" is not a good one. It reminds me of the argument about CPM education/licensure, aka "Getting a CNM is really expensive/it's wrong that you should have to become a nurse first/it takes so long, so we should approve/license all CPMs" [without attention to what kind of education/training they've had]. Many people want to be able to call themselves midwives and catch babies - I do! - but that doesn't mean we should make it easier to do that - just make it easier for people to access quality education. Ultimately it's not about serving the needs of the many people who would like to become midwives or IBCLCs - it's about serving the consumer. Yes, it sucks to have no support, but it can be worse to THINK you're getting quality care when you're not. Consumers are served by having more GOOD lactation professionals - not just more.

Rebecca said...

@Arual: Yours is a great example of why we need better training for everyone, along with the fact that you can get crappy advice from anyone regardless of their credential. I also hope you meet better IBCLCs in the future...there are so many of them out there!

@Emily: Everyone can get overconfident... One thing about the CLC class is that it goes by fast and there's not opportunities to practice those skills/knowledge with someone around to say "Nope, you remembered that wrong". I do love that the CLC offers such a great basic skills training for doulas etc. - the breastfeeding training for birth doulas is so minimal that I think all doulas can benefit from an extra course.