Open Letter: Barriers To The IBCLC Profession

The following is an open letter sent to International Lactation Consultant Association® (ILCA®) president Elizabeth Brooks. Lactation Matters is sharing this letter with the goal of sparking conversation before, during, and after the Lactation Summit (hosted by Lactation Education, Accreditation and Approval Review Committee (LEAARC), ILCA, and International Board of Lactation Consultant Examiners®(IBLCE®). We welcome your open and honest dialogue about barriers to the International Board Certified Lactation Consultant® (IBCLC®) profession in the comments and in your own community.

In her IBCLC Day address, Elizabeth Brooks, ILCA president, acknowledged the inequities to entering the profession. I thanked Elizabeth informally, and after a long discussion with her, decided to write this open letter for public consideration.

On IBCLC day, I opened my Facebook feed to find a sea of messages posted by Facebook friends thanking the IBCLCs who had inspired them or helped them on their path through the difficulties of breastfeeding. While I have also been inspired by many IBCLCs, instead of joining in the congratulations and well wishing, I felt a wave of regret for those people who do not have equal access to the field and who, despite their talents and experience, may never become IBCLCs.

In Europe, where I live, the number of practicing IBCLCs is very low. The new IBLCE exam prerequisites have made access to the profession very difficult (especially for non-health care professionals). Even those private practice IBCLCs and health care professionals who have the qualification have difficulty actually practicing with it.

Europe has an aging population. A review of health care education in the UK shows a distinct lack of maternal and infant health courses, and I think this is common across Europe. Because of a predicted decline in births, most resources are directed towards mental health nursing and aged care. Despite access to free or subsidized health care for a large number of Europeans, that health care does not include lactation support. Even when lactation support is identified as needed, the IBCLC credential is not recognized as the standard for delivering that care.

Here in Europe and in other parts of the world we need help promoting a qualification that is difficult to promote. The IBCLC qualification is known as the ‘gold standard,’ but unlike gold (which has a predictable mass), the prerequisites have changed consistently throughout its 30 years of existence. When people ask me to explain exactly what an IBCLC is and what an IBCLC has studied I begin with a “well, it depends . . ..”

We (breastfeeding advocates, providers and supporters) need a clear idea of what the profession is and what we want it to be. Currently the qualification is used predominantly as an add-on to existing health care professions. Non-health care professionals are following a precarious path through ‘patched together’ education; 14 health-science subjects from different faculties and institutions, 90 hours of lactation specific education from independent sources and a various assortment of practical hours with varying degrees of supervision.

Unlike other professions with a clearly outlined study path, navigating the IBCLC exam prerequisites requires skills and experience unrelated to those necessary for success at completing the required courses and practical hours – the system currently privileges those with prior tertiary education, familiarity with education institutions, independent study skills and, for those of us in Europe, internet access, and the economic means to affront unsubsidized private education.

Each country in Europe has an existing health care education system which is not organized along the same lines as the courses outlined in the Health Sciences Education Guide. The difficulties in finding courses that satisfy the specified requirements are forcing many of us to spend our ‘lactation education dollars’ in the US rather than within our own education systems, due to bureaucratic difficulties such as course names, length and content. This is an unfortunate loss of resources as our own education systems are often subsidized or free but don’t necessarily offer individual courses with the same division of content.

My hope is that IBLCE will recognize the resources that we do have instead of requiring a standard list of courses, which we do not have. Such a recognition could then help us open dialogue with our own institutions. We could ask for permission to access to the pre-existing courses that we require by emphasizing the need to train professionals within existing institutions, in turn promoting recognition of the qualification in our own countries. This could be a tangible way to demonstrate to our governments, education systems and health care systems the need for lactation education and professionally trained providers. In the interim, we also need help in simplifying access to the exam and assistance in sourcing universally available online courses that are accepted by IBLCE.

In opening opportunities for new IBCLC candidates, we should also focus on creating opportunities for those less advantaged and those from marginalized communities in order to increase diversity within the profession. Currently, the practical hours component of the prerequisites privileges health care professionals already in practice and those who can afford, and are eligible to, volunteer with mother-to-mother support counseling organizations.

This constitutes a barrier to those who do not have a health care degree, and those who are not mothers (including men), those who do not parent in a certain way, or who cannot afford to volunteer. Other analogous professions, including counseling, nursing, and midwifery, do not have these kinds of restrictions and as a result have a wider diversity of practitioners. We should be turning our gaze to the entry points of both the education and practical requirements and consider how to remove barriers to entry in order to create a system that truly welcomes candidates of all ages, genders, race, abilities, and sexual orientations.

The African American community is pioneering work in this area, creating systems that build on WIC peer-counsellor programs enabling IBCLC candidates to build on their existing experience under the guidance of qualified mentors. In Europe we do not have programs such as WIC (nor easy access to mentors nor academic programs) and there are growing numbers of independent peer counsellors, volunteer and professional, doulas, breastfeeding counsellors and lactation educators who are unable to use their experience towards the IBCLC exam.

These individuals could be encouraged to participate in a structured and supervised support network that could enrich and enlarge the small but significant pool of candidates who acquire experience via volunteer mother support organizations such as La Leche League International (LLLI). The mother support organizations recognised by IBLCE are not accessible to all, nor provide support to all. LLL has recently widened their application requirements to include men who have breastfed, a change in policy from two years ago when they refused the application of Trevor MacDonald. This is a positive step towards inclusion by the association which has a history of difficult relations with working mothers, single mothers and women in same-sex relations – factors that limit this organization (the world’s largest mother support organization) as an equitable entry point to the profession. I hope that other entry points for non-health care professionals will be recognized or created.

Lastly, there are many people with skills and experience from within underserved communities that could be serving communities worldwide, including indigenous, marginalized ethnicities, rapidly increasing migrant populations, the diversely abled and the LGBTIQ population. Our access to the exam is limited for the same reasons that our communities are underserved. Nearly three-quarters of the world’s IBCLCs reside in America (or serve in the American military) and even there many communities are unrepresented in the profession and underserved.

In lieu of statistics, we can look at the way the profession is described, the images used in breastfeeding literature, and the gendered language used by IBLCE and throughout the breastfeeding field generally. I think it is safe to say that the lactation profession is practiced predominantly by white, English speaking, middle-class, heterosexual, partnered, cisgender women. I know there are a few exceptions to that and I take my hat off to sole earners or primary breadwinners, people of color, LGBTIQ people, men, and those with linguistic challenges who have managed to enter and gain employment within the profession.

These were the thoughts that cast the cloud over the IBCLC for me, a cloud that lifted upon reading Elizabeth Brooks’ address, opening a much needed dialogue on barriers to the profession. The discussion that followed with her and others was, in the end, a cause for celebration of IBCLC day. I am currently an IBCLC exam candidate and believe strongly in creating a profession that is as equitable as it is professional. I am much looking forward to continuing this discussion at the Lactation Summit in Phoenix in July, where I will be an eager participant.

profile 02.14 edited II croppedAlice Farrow is an Australian who has lived most of her adult life in Italy where she is currently a single parent of two bilingual and bicultural children. A member of the LGBTIQ community and mother of a diversely abled breastfeeder (a daughter born with a cleft lip and palate), she writes on issues of inclusion and special needs in breastfeeding  support through her two websites www.languageofinclusion.com and www.cleftlipandpalatebreastfeeding.com.

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12 Responses to Open Letter: Barriers To The IBCLC Profession

  1. ECBrooks says:

    You have articulated clearly the myriad of challenges faced by those who seek nothing more than to obtain IBCLC certification, join the profession, and provide evidence-based support and compassionate care to new families. Breastfeeding and human milk use are a public health imperative. IBCLCs play a critical role when specialized lactation care is needed … support that differs significantly from peer counselor and primary healthcare provider help.

    The 27 July 2014 Lactation Summit Addressing Inequities within the Lactation Consultant Profession )http://www.ilca.org/i4a/pages/index.cfm?pageid=422) is a start. Your blog is an eye-and-ear-opener for those of us who are leaders in the professional association, educational accreditation organization, and certifying body. Unless we are prepared to first, truly, listen to those with “lived experience,” we cannot know what works, and what requires change.

    Thank you.

  2. Rachel says:

    I’m a La Leche League Leader and IBCLC, I first qualified by exam in 2002. I have a degree in Social and Political Sciences. I work now providing breastfeeding help and support at a drop-in in a Children’s Centre, for which the Children’s Centre pay me. (This is in addition to volunteer LLL work, and separate from it.) My co-LLL Leader also works at this drop-in, but she cannot be employed because she has a degree in Geography, and she cannot afford to do another first degree in science, which is what the new entry pathway requires. So we do the same work but she cannot be paid. This is not equitable. Also, it means she will not be able to continue with this service because she’ll need paid work. She loves helping breastfeeding families. Our drop-in is in danger of folding up if we cannot staff it. (I am vintage/retro/recycled/pre-loved, your choice of circumlocution for old!)

  3. This is a very important conversation. I think an important part of addressing the problem is creating more comprehensive IBCLC training programs that offer rigorous academic preparation AND hands on skill training and mentored clinical hours AND are appropriate and accessible to non-nurses, to working people, and to those with limited finances. Universities and community colleges with Schools of Nursing, of Public Health, and of Nutrition – how about it?

  4. I think the IBCLE could make it easy by just creating a formular for the course provider to fill in and certify that one has taken the course successfully. As you mention, many courses in Europe are of less cost for us living here and one would think that a university accredited in ones own country could have the IBCLEs trust in certify ones skills according to their requirements.

    Many start as a peer counsler and has a different background than health care staff. I totally agree in the need to intercept all these “breastfeeding nerds” since lactation is fysiology but breastfeeding is cultural. This should benefit a diversity rather than streamline.

    It is a thorn in the side to have to pay an amount of money for every course to find out if the course taken accredits the requirements when there are over 14 courses one have to take. This since IBCLE offices doesn´t exist in every country either. I wrote an email last fall and haven´t gotten a respond yet (suspect I will never get one.. ). This is also a huge problem. That it is hard to find out facts and one has to guess, guess and hope. When it could have been made much more simplefied.

    • Sara Lake says:

      Dear Ms. Hyttsen: I thank you for your feedback and am sorry to learn you did not receive a reply to your inquiry. I have asked the IBLCE European Regional Office to contact you regarding the same and apologize for any inconvenience to you.

      Sara Lake
      Executive Director
      IBLCE

  5. Jane Graves says:

    I live in the UK and am a second career breastfeeding peer supporter – (my qualification pre children was in librarianship!) I began volunteering 8 years ago with a local midwife run support group, and have been working for 5 years supporting mums to breastfeed on the telephone, paid by my local hospital. I fell in love with helping women breastfeed after attending a support group with my 4th child, getting the help I needed and then wanting to give something back. I want to make this my career but I have no recognised qualification – I don’t want to train as a nurse or midwife – so I am slowly working my way towards sitting the IBCLC exam in 2016.

    I support the changes IBCLE made in 2012 to require candidates without health professional qualifications to have background courses in health sciences. I first decided to aim for IBCLC in 2010: I could have ‘crammed’ and fulfilled the old criteria and sat the exam in 2011 under the old rules, but I felt that although I might be able to pass, I wasn’t sure I would be really ready to practice. So I decided to commit to the longer and more thorough process now required by the IBCLE. I need to fulfill 7 of the 8 courses for credit and all of the other 6 – so far I have completed 4. I have found doing the courses interesting and mostly they have broadened my understanding of breastfeeding issues.

    For myself the main barrier has been that the criteria about health background courses were insufficiently thought through when they were initially released. I understand that IBCLE cannot recommend courses – but it has been difficult and at times impossible to find out which courses will be regarded as suitable. I regard it as a great step forward that now IBCLE charge a small fee to verify courses (although it still seems to take weeks to get a response). However it has been frustrating recently to see courses verified which seem to be unsuitable under the criteria originally released. I have courses in my portfolio that may well not be suitable because I took a chance on going ahead with them at a time when IBCLE wouldn’t give an answer about whether specific courses would count.

    It seems to me that there is a pattern whereby IBCLE move the goalposts – as we say in the UK. They decided change is needed – and I don’t disagree with that – but then they announce changes where the detail is not sufficiently tied down. Please could they get all the details hammered out FIRST before they announce them and we spend our time, energy and money trying to fulfill them.

    It would also be only fair if IBCLE committed themselves to only change the criteria every 5 years or maybe every 10 years, so that those like myself, who need a long time to get all these courses, won’t be in the situation of the requirements changing during that time.

    I regard myself as really fortunate to be in a situation where I have been able to save money from my wages to finance my courses in health background education and specific breastfeeding training. My employers have been very supportive and I have also been very lucky to have been mentored by the IBCLC who works there, but money is tight in the NHS, and they have only been able to provide limited funding for one or two courses and conferences. I calculate that it will cost me about £3200 all told – I could have perhaps got some of the health background courses more cheaply, but I have chronic fatigue which limits my ability to attend evening classes, for example. This financial outlay is a major barrier. I think it would be very hard to find this amount of money if you were volunteering as a breastfeeding worker. The irony is that if you are a health professional it would be much cheaper, but you are likely to be working and therefore more able to afford it!

    I hope these points will help the conference to understand some of the struggles prospective candidates with no health professional background have to go through. I hope we will see future candidates facing less barriers to accessing this much needed profession.

  6. eurolacpuntnet says:

    I am one of the first 10 Dutch IBCLC’s, regarded as a senior LC, lectures in many LC courses and wouldn’t be able to sit the exam by today’s standards. My first education was in education and my path into lactation was as an LLLleader. Perhaps needless to say I do not agree with making IBCLC a healthcare profession add-on. I strongly believe lactation consultancy is as much an educational as an medical or an counselling profession. In fact, I think the profession would be best served if it were a primary profession, studied at colleges. That would tackle the obstacles mentioned in the above as well.

  7. Sonja Beck says:

    An amazing letter that brings up an important topic. And I learned something new today as I had never seen the term cisgender before! (Always a good day when I learn something.)

    I’ve been an IBCLC in California since 2001 and have had frustration over the changing pathways to reach the exam. Health professionals I know are also confused on how to become an IBCLC. I totally agree with the “it depends” when interested people ask me about getting into the lactation field. I am happy to know that the Lactation Summitt will begin to investigate this subject.

    People involved with breastfeeding need to be aware that we are supporting a basic human function, one that will set a child on a road to good health, both physically and mentally. We are caregivers and all new parents need a tender word or touch as they transition into a family, whether that comes from a professional, peer, family, friend, woman, man, or any of the rainbow of categories we may include ourselves in. We are all human.

  8. Yocheved Herrmann-Blanton says:

    Alice, thank you! The profession was created by non-professionals, through La Leche League. The skills to help mothers breastfeed were taught by mothers, but it is clear to me that any compassionate human being can develop the skill set! There might be a slight edge for a woman, who after all can directly relate to what it feels like to have her nipples stimulate her uterus, etc…..but again, I have seen many men have great compassion and humanity. And that is what it takes to teach what breastfeeding is…not about a fluid coming out of the chest, but about a relationship that lasts a lifetime. Our profession IS highly political, sadly, as woman are NOT valued per the monetary system, thus our fluid, our time does not count. Michel Odent makes a case for not having men present during birth, however, many are becoming much more aware of gender bending roles and the necessity of not pigeon holing any individual into any particular category. We who are training the next generation of IBCLC’s need to find ways towards inclusiveness. I believe we need to create a 100% apprenticeship program for those who would not be able to qualify due to all the barriers you mention. I have trained La Leche League Leaders this way. Looking forward to seeing you at the conference!

  9. Holly says:

    I am from the US and currently work as a breastfeeding peer counselor with WIC. I began working on my health science education last spring (2013) and will hopefully finish the spring of 2015. I also agree that there are significant barriers; to begin, I make a very low wage and receive only 250 hours of contact per year if I am counseling primarily by phone or email. Fortunately, I am also part of a pilot project to work in a hospital, but it will still take me at least 2 to 3 years to complete my clinical hours. I do not understand why mother support organizations require 1000 hours, because it is very difficult to achieve if all the requirements need to be within 5 years prior to the test. What if you have a child in the center? What if you are unable to counsel for some time due to unforeseen circumstances? With WIC, we are limited to 5 hours per MONTH of clinical work, so getting enough hours in person is not an option.
    My greatest concern, however, is that without being a Registered Nurse, that I will be unable, after investing my time into education and service, to find suitable employment. I do not feel that having a medical background automatically makes someone more competent to perform this work, and I often find that those of medical backgrounds treat breastfeeding, at times, with the same lens of pathology that birth is often viewed through.
    I have the opportunity to enter an accelerated nursing program next summer, but I do not have a passion for nursing, or wanting to be a nurse. Rather, I have a passion for relationships, listening to those struggling with breastfeeding, and helping them to help themselves, which comes from a counseling/psychology background, and not medicine. That said, I do feel the education required is necessary to understanding the science of lactation, but I would also like to see more programs available in US colleges and universities as an Associate or Bachelor degree that blend both lactation as a science and lactation counseling together.
    Lastly, I also share the same concerns as the author when it comes to diversity. Living in New Mexico, where the population is primarily hispanic/Latino/Native American, it is disheartening to see that IBCLCs that I have met are primarily white women (full disclosure-I am also a white). Yet, many of the peer counselors on the ground are more culturally diverse, but not able to create a career from the work they love; the experience does not come with the proper education to make that possible, and most places want an IBCLC to receive medical reimbursement.
    Thank you for opening the door to this conversation…it is very necessary and long overdue.

  10. mummymilk says:

    I qualified as a NCT Breastfeeding Counsellor in the UK in 2008. This is a level 4/5 Diploma accredited (back then) by the University of Bedfordshire. I believe it is now with Warwick University. I moved to NZ in 2009 and wanted to qualify as an LC. When I checked the prerequisites then, all I needed to do was complete the 90 hours of breastfeeding specific education. I left it for a year while my family got settled, and in that time the requirement changed so much that I would now be required to get a Health Sciences Degree. My desire to be an LC is to give people the confidence that I am trained well enough, and remain trained – my UK qualification is not recognised here…. very frustrating! I am also a LLL Leader, but I do not do that much as a leader. However, I do run a Breastfeeding Clinic twice a week, purely voluntary, set up as a Charity. I train Peer Supporters – we work to a good Code of Ethics similar to that of an LC. I carry out over 600 “consultations” of one sort or another with breastfeeding women each year. I attend conferences, workshops and study days at my local maternity hospital, I am in touch with midwives and LCs, I make sure I stay up to date, I find mentors and ensure I am not working alone in my development and progression… but I cannot qualify as an LC unless I get a degree…. I can’t afford the money or time – I would have to drop my breastfeeding clinic and I will not do that. The hours I work there aren’t recognised so I’d have to get hours elsewhere… I want to be an LC and continue to give my time free, but I can’t. I am not a health professional.

  11. Dear Ms. Farrow:
    I wanted to respond to what is clearly a heartfelt letter from you. Thank you for sharing your thoughts as well as for your interest in, and commitment to, the IBCLC credential.
    You have discussed a number of interesting and important issues in your letter.
    IBLCE is interested in a number of these important issues as well. IBLCE is a certification program with close to twenty-seven thousand certificants in 96 countries and growing. The examination is now offered annually in 15 to 17 languages. The IBLCE certification program has clearly experienced a number of successes over a relatively brief history, less than 30 years. However, until everyone who wants access to an IBCLC for lactation care has such access, there is more work to be done around the world. IBLCE is working in a number of ways to address issues important to the profession, many of which you touched upon in your letter.
    There are indeed a number of issues with respect to access to education. While IBLCE is a certification body and not directly involved in education, there are certainly challenges with respect to access to education. The IBLCE leadership felt it critically important to transition to eligibility requirements which include a foundation in the health sciences. While acknowledging the profession’s strong roots in mother-to-mother support, a background I myself am very proud to have and which I find extremely helpful in my own practice, the transition to the health sciences requirements was carefully discussed and considered by IBLCE. It was believed to be critically important so that IBCLCs would have the health sciences foundational knowledge which is critical to IBCLC practice. The decision was not made lightly yet IBLCE also appreciates that this transition is challenging. Issues regarding the evolution of professions over time are challenging, and are particularly acute with respect to relatively young professions, which the lactation consultant profession at twenty-nine years, indeed is.

    To address this issue in an appropriate manner, IBLCE, together with the independent professional association, the International Lactation Consultants Association, provided sponsorship to support the Lactation Education Accreditation and Approval Review Committee (LEAARC). IBLCE has provided annual sponsorship for many years. One aspect of LEAARC’s mission is to “promote the establishment of a structured, competency-based didactic standard that reflects the profession’s core curriculum. Recognizing the present diversity in type and length of lactation instruction, LEAARC reviews and recognizes didactic courses as well as accredited lactation programs in postsecondary institutions.” While support of LEAARC is an important step, LEAARC has a very ambitious mission with a great deal of work ahead and there is more to be done on the educational arena. IBLCE is looking at novel ways to address concerns about access to the profession while also recognizing that professional associations, academic institutions and private educators have a key role to play in examining these issues and affording constructive solutions.

    Also in support of examining these weighty and complex issues, IBLCE is serving as a sponsor of the upcoming summit, which will be looking at educational barriers, including educational barriers. around the globe. Again, an important, yet preliminary, step.

    IBLCE is also reaching out in other ways. Although IBLCE has a distinct international character and presence, two years ago, the IBLCE Board made the decision to heighten its international presence. In this spirit, in April of this year IBLCE leaders attended the European Lactation Consultants Alliance (ELACTA) Conference and met with leaders of ELACTA. In September 2013, the IBLCE Board held its meeting in Brazil and met with Brazilian IBCLCs and those interested in entering the profession and examined issues and concerns among those in lactation in that large and important country. IBLCE is very interested in learning from IBCLC leaders around the globe about their challenges and concerns and provide appropriate support where it can. IBLCE is very much reaching out where it can to listen to and examine those concerns.

    I would also like to address the issue regarding changing standards. Practice does evolve over time. New evidence-based research informs, enlightens and shapes practice. This is one key reason why, pursuant to best practices, a certification program is required to conduct periodic practice analyses, or studies premised on data, about a given profession or field. As has been announced, IBLCE will be disseminating a new practice analysis survey; the last practice analysis survey was several years ago. On the basis of this practice analysis data, IBLCE will, as is a best practice, review its certification eligibility and maintenance requirements asking such questions as “What does the data reveal about how practice has evolved? Are changes needed to eligibility and maintenance requirements? What knowledge is required for practice in the field?” Every reputable certification program conducts these studies periodically and is required to align its requirements with the current state of practice. Please know that changes will not necessarily take place, and any changes will be communicated years in advance, but that such a periodic examination and inquiry is important to both the relevance and integrity of the credential and the profession.
    To conclude, thank you for your thoughtful letter. Your letter raised some other issues which are clearly of concern to you and with which I can sympathize. While IBLCE, or other lactation organizations, cannot control the demographics or educational framework of any geographic region, the organization is open to hearing about experiences in accessing the credential and playing a key and appropriate role in examining and addressing such issues while maintaining the rigor of the credential. IBLCE looks forward to hearing about them in greater detail at the upcoming summit.
    On behalf of the IBLCE Board of Directors,

    Rachelle Lessen, MS, RD, IBCLC
    Chair

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