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.
Alice 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.