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?

Breastfeeding and Feminism, Day 2 (...2 weeks later)

My Lent resolution has apparently not yet translated into more posting! A few factors have contributed to that, among them my new full-time job(!) I have gone from per diem at the hospital working 24ish hours a week, to full-time working 36 hours a week (three 12-hour night shifts). Going from working 8-hour shifts to 12-hour shifts is a surprisingly big adjustment (although fortunately not as big an adjustment as beginning to work nights was.) There are drawbacks to my new schedule (less flexibility, losing several evenings, etc.) but the benefits are, well, the benefits! Apart from my grad school assistantships, I haven't had a job with health insurance since I was in AmeriCorps. I am looking forward to having good health insurance, along with retirement benefits. One of my goals in going to grad school was to finally get a "real" job with salary + benefits, and while it didn't happen in exactly the field I expected it to, I couldn't be more pleased (except for the part where I work nights. Hopefully someday I'll work days again!)

Now that I've made my excuses, long-delayed highlights from the second day of the Breastfeeding & Feminism conference:

* Possibly my favorite presentation of the day was Robbie Davis-Floyd's report on the International MotherBaby Childbirth Initiative. Based on the Baby-Friendly initiative, the IMBCI has outlined 10 Steps to optimal motherbaby maternity services, developed with the input of organizations around the world. Steps include treating every woman with respect and dignity, offering continuous labor support, providing evidence-based practices, and providing access to emergency OB care. Three sites have applied and been accepted to become demonstration sites, one each in Austria, Brazil, and Quebec, Canada. You can read more about the (very diverse!) demonstration sites here. She discussed more about the sites and more details of their applications. She also talked about sites that will be added soon, in South Africa, Mozambique, India, and - amazingly - the largest maternity hospital in the Philippines, which does 22,000 births a year (I cannot even imagine). It's inspirational to see institutions from countries with different levels of development and each with their own unique strengths and challenges, working on the aim of improving maternity care. I am so excited to see ow the demonstration projects go.

* Michelle Lauria, an OB-GYN from Dartmouth, gave a great talk on reducing late preterm birth, a project of the Northern New England Perinatal Quality Improvement Network. She also talked about eliminating elective inductions before 39 weeks, and in mothers who do not have a high enough Bishop's score. She said the key is to put power in the hands of the nursing staff with the hospital authorities backing them up; the doctors know if they send someone in for an induction who does not meet the guidelines, the charge nurse will send them right back home. She talked about the next step being setting stricter guidelines on ways that some doctors use to get around the restrictions; she gave the example of mildly elevated blood pressures without proteinuria being called pre-eclampsia and used as a reason to induce early.

She also discussed VBAC at some length. Her take on it was, in her region, it's all about the money - as in, medical malpractice insurance costs. In northern New England, which has a lot of isolated rural communities, she gave an example of a small regional hospital that wants to offer VBACs but would have to pay $120,000 more in malpractice insurance to do so. Given that they anticipate 2 VBACs a year, they would end up paying an extra $60,000 per VBAC. Her proposed solutions are both governmental: either medical malpractice reform of some kind, or for the government to coordinate regional VBAC centers. There would be one hospital in each region designated as the VBAC center, and all the other maternity hospitals would contribute towards the VBAC center's additional malpractice insurance. She considers this unrealistic without government intervention because of the nature of competition between hospitals.

* Beverly Rossman from Rush in Chicago did a very inspiring presentation on breastfeeding peer counselors in the NICU. The NICU breastfeeding peer counselors are truly peers - they are women who have personal breastfeeding experience with very low birthweight (VLBW) babies. She summarized some themes from qualitative interviews from mothers who worked with the peer counselors: instrumental support, emotional support, finding hope, empowerment, community, and emulation. Over and over again the interviewees talked about how much they identified with the peer counselors, how much hope they drew from seeing mothers who had been in their situation, and how important the emotional support was. It left me wanting a breastfeeding peer counselor program in our NICU so badly! (If you'd like to learn more and you have access to the Journal of Human Lactation, you can check out their journal article. Citation: Rossman, Meier, Engstrom, Verheed, Norr & Hill. "They've Walked in My Shoes": Mothers of Very Low Birth Weight Infants and Their Experiences with Breastfeeding Peer Counselors in the Neonatal Intensive Care Unit. JHL. 2011. 27(1):14-24.)


It was a great conferences with some great conversation! It was hard to choose between the CIMS and the BF & Feminism tracks sometimes because there was so much interesting stuff going on, but I'm glad they combined the conferences for the opportunity to pick and choose from both programs.

Sadly, I won't be able to go to the CLPP Reproductive Justice conference this year. Please, everyone who's going tell me all about it! I am determined to go next year.

Breastfeeding & Feminism: Day 1

I really need to take more notes at these things! So here are a few notes pulled out of my very scattered information overloaded brain:

- Eugene Declercq gave a great keynote on statistical trends in C-sections, VBAC, and other birth-related stuff. One of the most interesting sections was on homebirth. Still very tiny numbers, so hard to identify a definite overall upward trend, but it seems to be on the rise. He then broke the trends out by race, and that was fascinating: homebirth rates were the same or dropping for all races except for white women, who are clearly seeing an uptick. He reports that in the latest stats, 1% of all births to white women happened at home. That seemed high to me, but apparently that's what the statistics are telling us. I am not at all surprised, however, by the disparity.

- Bettina Lauf Forbes and Danielle Rigg of Best for Babes spoke about reframing breastfeeding, including how much they dislike the phrase "protect, promote, and support breastfeeding" - they want to replace it with "inspire, prepare, and empower moms". They really have a marketing mindset of helping introduce moms to breastfeeding via common consumer culture avenues like celebrity profiles, then help educate them on avoiding the "booby traps". As they pointed out, we have very high BF intention rates - we need to help moms achieve their personal goals!

- Keren Epstein-Gilboa, who came all the way from Canada, gave a really dynamic talk on breastfeeding and envy. She first had us imagine something that we really, really wanted - a job, a person, a house, whatever - and say how it made us felt. (Great!) Then we had to think about how we couldn't have it - and how that made us feel. (Well, pretty crappy.) Now how did we feel about that thing, and the person who had that thing instead of us? We often tell ourselves we didn't want it anyway, or that it really isn't that great, or we try to break it into parts. She used that introduction to discuss her research on the relationship of fathers to breastfeeding, and how different societies treat mothers and by extension how they treat breastfeeding, and also what it means for women who try to breastfeeding and aren't able to. I only wish she'd had more than 15 minutes!

That's all for now - I've got to start recharging my brain for tomorrow...

Upcoming plans

So last year, I gave up Facebook for Lent, deciding I was letting it suck too much of my time. It was a surprisingly scary thing to do at the beginning! I really, honestly found myself getting kind of anxious when the time came to log out for the last time. And then...yeah, it was totally fine. I kind of forgot it existed, and when the time came for me to get back on I would go days before remembering to log in again. It was nice!

Of course, since then my usage has crept up again and realizing Lent was coming up, I thought about it and decided to take another Facebook break this year. Along with an even scarier one... blog reading. I do love Google Reader... maybe a little too much. I find myself spending hours consuming and clicking and reading and thinking, which is all well and good, but can spiral into way too much time, and in the meantime I'll "star" a dozen more to go back and read in more depth, or as inspiration for a post of my own, etcetera and those just pile up. The productivity scale goes way down the farther I get sucked in. You all know how it is, right? This just seemed like a good opportunity to give it a break and see what else I can do with that time.

So if I'm a regular commenter on your blog and am quiet for the next, oh, 40 days or so - you have your explanation! And while I am giving up blog reading, I'm not giving up blog writing and in fact hoping that this break gives me more time to work on posts I've been letting sit for a long time. Hopefully you'll see a little more content here!

In non-Internet-related news (although hopefully a post-generating activity) I will be going to the Breastfeeding and Feminism/CIMS conference this Friday and Saturday. Very excited! Anyone else planning to go?

I am still thinking about attending the CLPP Reproductive Justice conference in April. I am really hoping to be able to go. I can't say enough good things about this conference - each time I've gone has been a fantastic experience. If I make it, I'll definitely be posting here about it!

That's all for tonight...just posted my Facebook farewell and am ready to begin my Internet fast!

"I would juggle speculums if they asked"

Do yourself a favor and read this long, funny, and compelling article by an abortion-provider-in-training. Some of my favorite excerpts:

It all breaks down to this: no one is immune to mistakes, whether it’s a mistake of their own making or (more likely) an end effect of the system, especially our fucked-up broken medical system I hate representing. (Sorry, system! Had to say it.) If you think I am making too many excuses for my patients, I will let you know that I am often one of the first people to make excuses for them in their lives and am happy to do so for no fee whatsoever. I would juggle speculums if they asked. I have not yet been asked to do this.

...

Up until recently I’d come out of any closet I found myself in — queer, non-monogamous, I fucking love Tool still, whatever — not that I live to hear the drink-choking sound, but because, to me, coming out was just one of the ways I could pay back the privileges that had been arbitrarily bestowed upon me (educated! white-appearing! “normal!”). My responsibility to normalize as much as I could. But training as an abortion provider is the first thing in my life that I hold back on spilling about. At the core of it, there’s a huge gap between saying “I had one” and saying “I do them.” I don’t want to alienate people. And nothing else I’ve ever done or been has felt like a direct invitation to a motivated someone out there to kill me and get away with it.

...

I speak of my abortion as a positive experience, not to secure the “most awesome abortion” prize (hello judges…?) but to save a seat for the possibility that this doesn’t have to be the worst thing that ever happened to you in your whole life. I don’t want it to in any way represent anyone else’s experience or make them feel disavowed of their own. So let me say: this is my personal experience with abortion! It was positive in every respect. It made me want to help other people also have as positive an experience as possible, so I went into the business. If you think that’s a bullshit line, or it makes you uncomfortable to think about abortion as something that could possibly be positive for a person, think of why you're a person who doesn't want someone to do the best that they can under the circumstances they're in.

If you read the whole thing, you'll learn about how she handles pro-life patients who come for abortions, her interaction with a female soldier who had to fly back from Afghanistan for an abortion, and her reflections on the distinction the law makes between MDs and advanced nurse-practitioners, just for this one fairly simple procedure. I am blown away by her compassion and courage. Please read it!

I found this post through my friend Melissa's new blog in the Feministing community. Melissa comments:

Approaching reproductive justice from a position of love and respect for women means that we recognize the varied experiences women have. Certainly, abortion is a difficult and even harrowing choice for some. But for others, abortion is a positive move forward on their journey to being the person, the partner, or the mother they want to become. If we ignore the positive experiences of those women, we’re adding to the stigma of abortion. To put it simply, although no woman wants an abortion, not every abortion is a tragedy.

Keep an eye out for more posts by Melissa! She is awesome.

Choosing and getting into MPH programs: Part 5: Getting funded

At long last, the conclusion to my MPH series! I hope it has been helpful to people out there. Here's the full list of the series:

Part 1: Should you even get an MPH?
Part 2: What is a Master's in Public Health, anyway?
Part 3: Which MPH program(s) should you apply to?
Part 4: Getting in

So! Getting funded.

There are, as far as I can tell, the following ways to get funded for your MPH:
1) Loans (federal or private). Obviously, these are the least preferable as you will have to pay them back!
2) Grants: the school pays part of your tuition, and you are not obliged to pay them back.
3) Assistantships/fellowships/etc.: these come under several different names, but you are generally employed by the university - doing something like working on a research project, assisting professors, TAing classes - and in return get some or all of your tuition paid for. Sometimes these also come with a monthly stipend.
4) Outside fellowships/scholarships: Funding you apply for completely independently of the university
5) Tuition assistance as an employee of the university: Many schools will let employees take one free course a semester, and/or offer a discount for classes
6) Tuition assistance as an employee of a lovely, generous outside company: Some companies/organizations will pay for their employees to take classes or pursue a particular degree that is relevant to their workplace

(Does anyone have other sources to add to this list?)

So how do you sort this all out and figure out how YOU will pay for school?

Again, I'll tell you a little story to start. When I applied to schools, I basically figured nobody would offer me a full ride, and nobody would offer me zero aid at all - they would all offer me some variable amount of aid. I also figured I had relatively little control over whether or not I got said aid.

Come decision-time, I discovered that what I thought was my first choice was offering me basically nothing. They just deducted the expected family contribution from their tuition, and offered me the rest in loans. That really dampened my enthusiasm, along with a campus visit that made me realize this wasn't really the ideal program I'd thought it would be. On the heels of that realization I got an offer from another school for a full fellowship my first year, with the possibility of finding more funding my second. I then visited the school that had been my second choice, had great interactions with some faculty there, told them about my full-funding offer from the other school, and they offered me what amounted to a third of their tuition in grants - the rest I would still need to cover or take out loans for.

So, so much for my ideas that I would get all the same funding offers and had no control over the process! I basically lucked my way into a great situation, despite having started the process with a lot of misconceptions. (If you're wondering what the end of the story is - I weighed my options with no small amount of agonizing, and ended up taking the fellowship. And I've never regretted it!) So let's talk about a few things I learned:

You do have control in some situations - and if you don't, you should find out.

At What-I-Thought-Was-My-First-Choice, I talked with a faculty member, with the administrative director of the program I was applying to, and with a financial aid officer. I also talked to a student there I happened to know. Everyone told me the same thing: you can only avoid paying full price if you find a position as a full-time employee, and go to school part-time using your employee tuition remission. There were literally hundreds of applications for every posted position. I had very little control in that situation! I was not one of the people at their accepted students day still asking about how to get funding - I already knew the score.

Talk with students, administrators, and faculty realistically to get an honest assessment of whether this program could be affordable for you. Even if you don't have control, at least you'll know about it.

At Second-Choice, I had more control than I realized. By meeting with faculty and expressing my enthusiasm for their program and talking to them about my other offer, I was able to get an offer of more grants - although still not what I would have liked.

If you get competing offers, let the other schools know diplomatically, while letting them know how much you'd like to be able to attend their program.

At Where-I-Ended-Up-Going, I had way more control than I realized until I got to campus. I had a fellowship that gave me tuition remission + a stipend, but other students had assistantships that gave them the same thing, and they had come to campus to meet with faculty and network for assistantships before they were even accepted. Knowing I would need something for my second year, I did the same and my fantastic advisor helped me find an assistantship for my second year.

At our school, not everyone was promised an assistantship, and the positions weren't generally posted - your advisor might talk to somebody who had one to offer, or you might hear from a friend that she was quitting hers for a different position. Networking was a necessity! At a couple other schools I applied to, they more or less said upfront that they would help anyone who wanted an assistantship find one.

Again, talk to faculty, students, and administrators to find out how you can get funding, and network, network, network! I told everyone I talked to at the end of my first year that I was looking for funding. Don't be shy!

Continuing in the networking theme, look for funding sources outside your department. If you speak German, a TAship in the German department could get you just as much tuition remission as one in the MPH program. If your school offers employee tuition assistance, working for the admissions office full-time won't get you through school as quickly, but it could mean a lot of $$ saved.

If you'd like to try to get funding from an outside source, many schools have a listserv that lists opportunities for outside fellowships and funding you can apply for. Also keep an eye out for programs that the university administers, but come from outside sources: I could kick myself for not applying to the Foreign Language Area Studies Program.

Important consideration for public universities: It's important to find out who can be considered a resident for tuition purposes, and how to establish your residency. Some states are huge sticklers - you have to be living there for many years before you can be a resident and provide signed proof from your landlord, your great-grandmother, and God. Some are much more relaxed, with shorter terms and less proof needed. The difference between in-state and out-of-state can be huge, so investigate this carefully. (Also check to see if the new state has an education compact with your home state, where the states agree to offer in-state tuition reciprocally to each other's residents.)

Finally, be realistic about where this program will get you financially and what you're able to pay back if you'll need to take out loans. I found the NY Times article Is Law School a Losing Game?, to be great reading for anyone considering any type of graduate school. Here's an excerpt:

Compared with the life he left four years ago, he has lost ground. That research position in Newark, he figures, would pay him $60,000 a year now, with benefits. Instead, he’s vying with a crowd for jobs that pay at rates just a little higher, but that last only a few weeks at a time, with no benefits. And he’s a quarter-million dollars in the hole.

At least no MPH will put you a quarter-million dollars in debt! But let's be real: we're not in a good economy right now. Think carefully about whether graduate school will put you in a better situation - financially, career-wise, health-and-happiness-wise - before you commit to the debt it can entail. Don't just ignore a lower-cost program that you love less. I loved What-I-Thought-Was-My-First-Choice; then I loved Second-Choice; I was really unsure about Where-I-Ended-Up-Going. I finally made the decision by saying to myself, "Any school you go to, some parts of it are going to make you pissed off or seem useless or that you just hate. You might as well hate them for free." Like I said, I've never regretted that choice! (Just to clarify, I ended up liking my program just fine, but there were of course parts that drove me nuts.)

This concludes my extremely long-drawn-out series! I hope it's been helpful to people out there (and continues to be). (If you're thinking about e-mailing me with questions, please read through the whole series to see if I've already answered them.)

Best of luck with your MPH journey!

Happy IBCLC Day!

Happy IBCLC Day! Since I didn't get around to be preparing a post, I'm throwing another breastfeeding-theme link party:

* Dou-la-la on loving her IBCLC, finding a good one, and why we need them.

* More about telling the real IBCLCs from the not-so-real.

* ILCA has an appreciation certificate to give to your favorite IBCLC.

* An IBCLC shares her personal story of overcoming challenges breastfeeding a baby with Kabuki syndrome.

Many mothers are talking today about how grateful they are for the IBCLCs who helped them feed their babies. I have a bit of a different take: I want to reiterate my gratitude for the IBCLCs who are stepping up to help train the next generation -- especially the ones who inspired and trained me, and continue to teach me every time I work with them. Without them, I could never have achieved my dream and I am so grateful!