Constitutional challenge to lactation consultant license moves forward

The team at Reaching Our Sisters Everywhere (ROSE) exemplifies resilience through tumultuous times. A bright spot shone through tragic recent events when the Georgia Supreme Court unanimously ruled in May 2020 that ROSE’s constitutional challenge to the state’s 2016 Georgia Lactation Consultant Practice Act will go forward.

Source: United States Breastfeeding Committee.

Our Milky Way spoke with ROSE Chief Empowerment (CEO) and Change Leader Kimarie Bugg, DNP/FNP-BC/MPH/IBCLC/CLC, Vice President Mary Nicholson Jackson, CLC and Program Director Andrea Serano, CLC, IBCLC who provided an update and commentary on the case. 

The team says that the recent reversal feels like a victory because it means that the 2016 law is still not enforceable and lactation care providers (LCPs) with any credential can continue their work. 

“The problem is that it’s still being misinterpreted in some places,” Jackson explains. “Sometimes trying to figure out what’s going on is the real concern.”

The Georgia Lactation Consultant Practice Act calls to prohibit provision of lactation care and services for compensation without obtaining IBCLC licensure. But in June 2018, the court put a freeze on the implementation of the law after Jackson, in partnership with the Institute for Justice (IJ) and ROSE, filed a lawsuit to preserve the right to earn an honest living.

The recent reversal affects close to 1,000 Certified Lactation Counselors (CLCs) among other breastfeeding helpers practicing in Georgia, all of whom would have not been lawfully permitted to continue their work under the law after July 2018. 

The ROSE team explains that while LCPs continue to legally offer services and support, there’s still some confusion within the community. Individuals lobbying for the Lactation Consultant Practice Act have offered up erroneous guidance at places of employment for example.

Especially in the current context of Covid-19, the team expresses relief that they and other lactation supporters are still able to provide support to families. Many long-standing and already-dire situations have been illuminated and compounded during the pandemic, like labor and birth support. 

In Georgia, only one support person is allowed to accompany a laboring person in certain maternity care facilities, and that support person is not allowed to leave and return to the hospital.  In many cases, this restriction is not sustainable for families who have other children or employment obligations.  

“We know that if [the law] would have been in effect, [birthing people] could not fall back on the resources that they know of and are familiar with after already being traumatized after labor and birth,” Bugg explains.  

Source: United States Breastfeeding Committee.

Racial inequities and structural racism have been brought to the forefront of our national conversation especially in light of Covid-19, and the issues at hand are no different in the world of lactation.

Not surprisingly, some have suggested that the entire premise of the Lactation Consultant Practice Act is fraught with racism. 

The case is not only about economic freedom, but equally important, access to lactation care especially in marginalized communities. 

Jackson’s petition points out that “the Act defeats its own purpose of promoting public health because it will, overnight, put hundreds of highly qualified lactation consultants… out of business. This will dramatically reduce breastfeeding support statewide, particularly in the minority and rural communities where CLCs are most active.” 

Pages 19 to 25 of the petition detail ways in which the Act causes harm to LCPs including those who work as milk lab technicians, Baby Café support people, military families, and the list goes on. 

In Why is That IBCLC Licensure Lawsuit in Georgia Such a Big Deal? author Liz Brooks, JD, IBCLC, FILCA details how lactation professionals of color are disproportionately impacted by the 2016 Act citing one example in particular where an African American RD IBCLC practitioner of many years had her application halted.

Brooks writes, “The systemic racism is made obvious because an IBCLC of color now has to take the time, and money, and lawyer up, and dig through paper work from 29 years ago, and file an appeal, and show people that she is an excellent, honest, forthright person who just wants to **continue** working to help families breastfeed/access human milk, which is what she was showing them when she filed her license application in the first place.” 

IJ explains that the “drive toward licensure is not motivated by health or safety concerns, but rather by IBCLCs’ interest in billing health insurance companies for their services.”

“In 2010, the Affordable Care Act mandated that insurance companies provide coverage for lactation services. Since then, insurance companies have used licensure as a means of limiting the expense of that coverage. To ensure they could bill insurance companies, the IBCLCs’ lobbyists have begun pushing state-mandated licenses across the country to artificially differentiate IBCLCs from CLCs,” the IJ statement continues. 

Source: United States Breastfeeding Committee.

SELCA released a response in regard to the Georgia Lactation Consultant Practice Act claiming that the law’s passing “has already improved access to clinical lactation care” citing new jobs, a community college program, and the promise of in-network lactation consultants for mothers using Medicaid. 

The ROSE team reports that this large scale change has not transpired. 

“That panacea that they thought was going to happen has not happened,” Bugg says.  

Again in Why is That IBCLC Licensure Lawsuit in Georgia Such a Big Deal? Brooks makes note:

“Who in the heck thinks any license, waived high over their head by an IBCLC, will now instantly generate credibility, job offers, insurance company cooperation, money in the bank? Anything having to do with payment for/coverage of health care services in the USA in 2018 is a humongous pain-in-the-neck. Ask any hospital, doctor, nurse, midwife, speech therapist, dentist, etc etc etc just how easy-peasy it is to see patients, spend quality time with them, have all services fairly and easily covered, and so on. Yeah. Not so much.

I’ve said it countless times: The issue should be about HOW to pay [for lactation care, from counseling on up through skilled clinical care], not WHO to pay [which is what flawed and even better-than-most licensing bills necessarily must focus on].” 

While ROSE moves forward, Serano urges maternal child health advocates to keep the issue of licensure on the radar on a state-by-state basis. When legislation is presented, look at it through an equitable lens, she suggests. Educate local and federal legislators. 

On this note, starting at the state level is an effective way to vindicate rights for others, as pointed out in IJ’s video Can the Government Throw You Out of Work? (Not in Some States!). An IJ attorney explains that the U.S. has a long history of looking at what state high courts have done, and that it’s a traditional method for achieving constitutional change. 

It’s important to make clear that it is not solely the fault of one or a handful of organizations or individuals for carrying out a racist agenda. We are all called to this work, striving for an antiracist society. 

You can stay up to date and support this ongoing case here.  

Spotlight on Fédora Bernard, Program Officer at The Right Livelihood Foundation

Fédora Bernard is currently Program Officer at The Right Livelihood Foundation, an organization established to “‘honour and support courageous people solving global problems’… now widely known as the ‘Alternative Nobel Prize’”. 

Bernard presenting in Rio.

Before transitioning into her work at The Right Livelihood, Bernard served as Geneva Association for Baby Food and International Liaison Office of the IBFAN Network (GIFA) Program Officer beginning in April 2019, having just newly graduated from the Institut des Hautes Etudes Internationales et du Développement with a Masters in International Affairs. 

This week, Our Milky Way is pleased to share a Q&A session with Bernard. 

Q: Please share a few highlights during your time with IBFAN. 

A: I am deeply passionate about human rights and GIFA was specialized in exactly that. I think that throughout my time at IBFAN, some highlights would probably be the sessions of the Committee on the Rights of the Child that I attended and advocated at, the World Health Assembly, the fifth session of the Open-ended intergovernmental working group on transnational corporations and other business enterprises with respect to human rights and of course, the World Breastfeeding Conference in Rio. They were all avenues where we could raise awareness and advocate for better national policies.

Q:  What would you consider your greatest triumph with IBFAN?

A: I am not sure I could speak of triumph, at the end of the day my time with IBFAN was quite short and all I did was trying to keep up with the amazing work that has been done by the Geneva office for the past 40 years. Nevertheless, I am very proud of the achievements with the Committee on the Rights of the Child, as during my time with IBFAN, “breastfeeding” was mentioned in almost all concluding observations.

Q: In November 2019, you had the opportunity to present IBFAN’s Green Feeding documents. What was that like? How was it received by participants at the World Breastfeeding Conference? 

A: It was an incredible experience, it was an honor to prepare this with Alison Linnecar, who wrote the document and to present it along with experts in the field. I don’t think that I can define myself as an expert, let alone a breastfeeding expert, but I am starting a career in advocacy. I therefore decided that I wanted to emphasize how the Green Feeding Documents could be used as an advocacy tool from an environmental perspective. Therefore, while Alison explained the science behind all of it, I focused on the link between breastfeeding and human rights, more in particular how it can be used in relation to the right to a safe, healthy environment. At the end of the presentation, I was so happy to see that most people in the audience wanted a copy of the green feeding documents…I thought that 30 copies would be enough, but clearly, I was wrong! I wish I had brought more.

Jose Angel Rodriguez-Reyes, expert of the Committee on the Rights of the Child pictured alongside Bernard.

Q: In your piece BREASTFEEDING: BEYOND “WHAT IS BEST FOR YOUR CHILD”, you mention the WHO/UNICEF Global Strategy on Infant and Young Child Feeding to Protect, Promote and Support Breastfeeding. We have the framework for better global health outcomes; What is holding us back? Is there one significant barrier standing in the way of a better world? 

A: I believe that from a political perspective, two things are holding us back: The first being the patriarchy and political systems dominated by men. As long as women will not be allowed to play a greater role in global health governance and domestic politics, public health issues such as breastfeeding or issues surrounding menstrual health will not be given the right amount of attention. 

The second element is political will, which is deeply related to the first. Breastfeeding is only seen as a public health issue in developing countries, and aggressive marketing from the formula industry has managed to convince women themselves that they are actually more empowered if they don’t breastfeed. Breastfeeding is thus seen as a weight imposed on them rather than a right that should be protected, promoted and supported by governments. In some societies, it is indeed currently a real hurdle for women to achieve their breastfeeding goals but instead of women in their breastfeeding journeys benefiting from policies, they are given a bottle. I am of the idea that improved breastfeeding policies are not only a matter of public health but also of women’s rights. 

Q: Any advice on how to navigate a climate where people dispute basic facts?

A: That is a very difficult question…Especially because those disputing basic facts are often deeply attached to their position and will give you alternative “facts”…I believe very much in trusted sources, and would always advise these people to check their sources and question them. For instance, if someone shows me an article from the industry containing “facts on breastfeeding” I would draw their attention on why this article could be biased and not based on adequate scientific evidence.

Q: Breastfeeding is a topic that spans across all disciplines. Will you please give us a glimpse into the work you’re doing at The Right Livelihood? 

A: The Right Livelihood Foundation honors and supports courageous people solving global problems, in all disciplines. IBFAN is actually one of them. With civil society space shrinking all over the world, human rights defenders are facing increasing difficulties, which is very true also for breastfeeding advocates. My work at the foundation therefore consists in using the advocacy skills that I developed with IBFAN, to support laureates all over the world.

Lactation Counselor Training Course (LCTC) offered completely online for first time ever

In this uncertain time, it can be helpful to remember that we have control over the way we respond to the things we don’t have control over. Healthy Children Project joins individuals, businesses and organizations that have had to adapt to this strange, challenging Covid-19 situation. 

“When you face challenges, we have two choices: Let it stop you or find a way to grow and make a difference, even during challenging times. Now, more than ever, lactation counselors are needed to promote, protect and support breastfeeding families, even though we temporarily find ourselves in a place where face-to-face courses can’t happen,” says Karin Cadwell, Healthy Children Project’s executive director. 

Since social distancing and safer-at-home policies have been implemented, Healthy Children Project (HCP) was propelled to use this as an opportunity to offer the Lactation Counselor Training Course (LCTC) completely online for the first time ever. 

“While we still strongly believe that the experience of being together for the LCTC course has provided wonderful opportunities for meeting new friends and colleagues and networking, the changing times have propelled us to revisit the course delivery options,” Cadwell says. 

ALPP will offer an online, remotely-proctored CLC exam starting this week

The LCTC course combines up-to-date high level evidence, counseling training, policy and practice.

“I have learned so much already that medical school, 20 years of practicing and nursing four babies never taught me. (I am only in the second section!)” one participant shares. 

Another participant shares: “I was extremely happy with this course, as it was taught in a way that was inclusive, free of bias, and with much knowledge. In addition, the evidence that was provided was exceptional. Though I was not able to do this course in person, the instructors created a course that was not only highly educational, but also enjoyable. Thank you again to all that made this course happen.”

Photo by Charles Deluvio on Unsplash

The online LCTC is a self-paced online course presented in an engaging and energetic format through videos, self-check questions and competency verification and twice-weekly office hours with faculty to answer additional questions for online participants. 

“I am truly enjoying the format of this course and it definitely helps that you are all so entertaining and fun! I feel like I am sitting in your living room and you are telling me everything you know and it is quite lovely!” on participant exclaims.

The course should take 52 hours to complete (just like the in-person version).

“I’m so impressed with our participants. They are working on the course when they get back from a long day working in the hospital or in between their kids online school zoom meetings. They are finding ways to grow and learn, even with this new ‘normal’ we are all experiencing,” according to Healthy Children Project faculty Kajsa Brimdyr.

Offering the LCTC online has produced some unexpected benefits like accessibility. 

“I love that we are able to offer this to those who need the flexibility of online learning, those who may not be able to get five days off in a row can take this course on their own time, in a way that works for busy lives and schedules,” says Brimdyr.

“I enjoyed the teaching methods utilized and enjoyed the ability to work on training while having the ability to pause and do other duties for my employment as well,” another participant attests.

What’s more, faculty has gotten creative about how to best replicate the face-to-face experience. 

“The office hours are a popular aspect of the new online class,” says Healthy Children Project’s Anna Blair. “Karin and I have had a great time getting to know the participants and help them think about how to integrate the new information into their practice. It’s really fun. My dog, Sandy, occasionally joins us and I love seeing all the faces (and participants’ babies and dogs) on the screen during the office hours.” 

Blair continues, “It is so nice to connect with the participants who are going through this journey.” 

Participants have also shared that one of their favorite parts of the course is  the virtual office hours with faculty. 

“It is really helpful hearing some of the questions and answers people are asking/getting,” one explains. 

Participants can email questions in advance or ask questions during the office hours in the chat feature of the program. In the absence of in-person learning, this feature replicates the value of hearing others’ questions. Each office hour section is logged and labeled by topic so that students can revisit and review the questions at their convenience. 

Photo by Richard Jaimes on Unsplash

“We kept thinking about the phrase ‘Laurus crescit in arduis’ –Laurel grows in steep and difficult places,” Cadwell begins. “Not only have we seen amazing stories of resilience in the news and with our friends, our team at Healthy Children has been focused on making a difference in the world. We all have, and need, the opportunity to bloom. Learning together, we can share our experiences and knowledge. We have loved hearing from our participants during the course – their ideas, experiences and future plans. We all can work together to make a difference for breastfeeding families.”


To register for the Online Lactation Counselor Training, please click here.

Breastfeeding in shelters

Among the many effects of the novel coronavirus, the pandemic has exposed our nation’s deficiencies: emergency unpreparedness, racial health disparities, our “highly polarized, fragmented, and individualistic society…” (I would add arrogant), and the failure of capitalism.  In marginalized populations, poverty, health inequities, and other burdens are amplified during an outbreak or other emergency. 

Long before the pandemic hit, individuals and advocacy organizations have been ringing the alarm, calling for better access to education, better healthcare, and equity and justice for all.

Of these trailblazers is Powerhouse Nikki Lee RN, BSN, MS, Mother of 2, IBCLC,RLC, CCE, CIMI, CST (cert.appl.), ANLC, CKC, RYT whose recent endeavor includes creating and implementing the 10 Steps to a Breastfeeding Friendly Shelter

In her role at the City of Philadelphia Department of Public Health, Lee noticed the challenges breastfeeding people face in shelters. 

The barriers are a result of our cultural attitude toward lactating people and misunderstandings about their bodies and needs. 

Lee talks about issues of privacy and ‘fairness’ in a shelter. Organizational dress codes often require residents to dress modestly, so when a person exposes their breasts to feed a baby, other residents can wonder why they’re not allowed to wear short shorts. Parents can express concern about the teenage boys in their families seeing breasts while a baby is being fed.

There’s the concern over safe milk storage and the mythology around reimbursement through the Child and Adult Care Food Program. Shelter staff may believe that if a mother breastfeeds, the facility will lose money to buy food because the allotted amount for infant formula isn’t getting used. Lee clarifies that if a mother breastfeeds, the institution will have more money to spend on food.  

Just like in the rest of the US, there tends to be a push for formula feeding because the baby’s intake is easily measured, and staff are more comfortable with what is familiar, i.e. bottle-feeding

Lee continues, “There is a genuine honesty from people who don’t understand anything about breastfeeding, ‘Why are we breastfeeding?’ ‘Why are we bothering?’”  Staff in hospitals have been educated about breastfeeding over the past few decades; staff in shelters have not.

So when she conducts trainings, she starts at the rudimentary level of ‘what are mammals?’ 

“All the worst mythology that you can imagine is in the shelter,” Lee says. “All the worst in how society treats mothers and babies gets magnified in shelters.” 

With the problem identified, Lee says she started “from scratch in a way,” looking for a written policy to support breastfeeding people.  Early on in her search, she followed up on a news story featuring a homeless mother in Hawaii. She posted inquiries on Lactnet, CDC listserv, international online forums, Facebook groups, and reached out to shelters at random wondering if they had breastfeeding policies . 

“Nothing,” Lee reports. “There is probably a shelter somewhere that has a policy, but after two years of a global search, I wasn’t able to find it.” 

In all her search,  Lee found one published document— a Canadian study looking at the factors that influence breastfeeding practices of mothers living in a maternity shelter– that could be helpful. 

Lee wrote the first draft of the 10 Steps to a Breastfeeding Friendly Shelter with policies like the Ten Steps to Successful Breastfeeding and Ten Steps to Breastfeeding-Friendly Child Care in mind. 

She sent it out to colleagues at CHOP’s Homeless Health Initiative for feedback, and for quite a while, there was none. Lee’s colleague Melissa Berrios Johnson, MSW,  a social work trainer with HHI, and the convenor of its breastfeeding workgroup subcommittee, helped to make the policy reality. 

Partner agency Philadelphia Health Management Corporation (PHMC) received a grant that funded research which took the policy to four different shelters for staff and resident feedback. 

“Everyone, residents and staff alike, felt this policy was important and feasible,” Lee says. 

PHMC’s next step was to identify a shelter staff member to become a breastfeeding champion. This champion would be provided with free breastfeeding training, and receive an honorarium.

As program oversight changed though, “breastfeeding champion” became a job, with a list of responsibilities. So far, Lee says they’ve only found four people out of 10 shelters who are willing to take on the task.

“There are some folks in shelters working hard to make things better,” Lee says. “They are those champions, most of whom have breastfed themselves.”

Currently, Lee and colleagues are in the process of developing training for staff members and ironing out how to help staff implement the policy.  

Lee’s and co-authors Alexandra Ernst MPH, and Vanesa Karamanian MD, MPH landmark paper about the 10 Steps to a Breastfeeding Friendly Shelter has been submitted to the  Journal of Human Lactation (JHL)

At present, COVID has put all of this work on hold.

A time for renewal

On one of my favorite walking routes, there is a beautiful oak tree that shades the street corner. Its sprawling roots heave through the sidewalk. One day, a dreamy song played through my earbuds, and as I walked toward the tree I felt the urge– almost like a spiritual calling– to touch its sturdy bark. Making contact with its trunk, a tickling, buzzing static traveled through my arm and zapped my ears like some energy had traveled through the cord on my earbuds. Stunned, I stepped back and gazed up at the oak’s gangly branches overhead, for a second believing that I’d connected with some otherworldly force. The sun shone down on the scene, casting a stark outline between the tree’s branches when I realized they were intertwined with telephone wires overhead.

Human innovation and nature entangled. 

April 22, 2020 marked the 50th anniversary of Earth Day and as this video points out, while we breathe through masks, our planet breathes a sigh of relief.

Healthy Children Project faculty, Master Herbalist, Certified Aromatherapist and author of  Growing Green Families: A Guide for Natural Families and Healthy Homes Donna Walls, RN, BSN, IBCLC, ICCE, ANLC agrees that Earth Day this year has a “different look.” 

“Around the world we are seeing the rebound of the earth when there is reduced human impact,” she says. “We see fish returning to the waters of Venice, kangaroos jumping in the streets of Sydney and comparison pictures of Los Angeles two months ago and now with clear, blue skies.” 

For the first time in decades, air pollution has cleared enough to reveal mountaintops from over 100 miles away. (Find pictures here and here.)  

Walls wonders if these spectacular phenomena will motivate humans to better care for our planet moving forward. 

She explains: “Being a maternity nurse for many years I usually go directly to ‘how does this impact new families?’ Maybe this is the opportunity to educate families on a cleaner life for our children, grandchildren and the planet.”

In 2013, Walls pioneered Miami Valley Hospital’s Green Team in an effort to provide safer, toxin-free products for families. 

“Anyone who says healthcare is not about cleaning up the environment is not well,” she laughs.

The Green Team worked to eliminate disposable diapers, formaldehyde-layden mattresses and unsafe, employee hand soaps, Walls reports. They found a clean, safe line of products and ultimately saved money.

Looking ahead, Walls poses: “At this time of renewal for the earth, can we make it the beginning of a new way of thinking, starting with the care and feeding of the newest members of the human race?” 

The environmental cost of infant formula milk is well documented in some countries. 

For instance, “For the UK alone, carbon emission savings gained by supporting mothers to breastfeed would equate to taking between 50,000 and 77,500 cars off the road each year,” recorded in research by UKRI Future Leaders Fellow at Imperial College London

IBFAN and BPNI published Formula for Disaster , a document that details infant formula’s detrimental impact on the environment and by contrast, breastfeeding’s sustainability. 

WABA also includes information on “the most ecologically sound food available to humans”– breastmilk. 

Bethany Kotlar, MPH, Program Manager, Center of Excellence in Maternal and Child Health at Harvard Chan School Center of Excellence writes in Amidst the COVID-19 Pandemic, We Must Remember Maternal Health, “The pandemic gives us the unique opportunity to reassess the cracks in our society…” 

We’ve been granted the opportunity to reevaluate our responsibility to our planet and pledge to protect it so that we may continue to receive its bounty and find solace in its beauty. 

“Treat the earth well. It was not given to you by your parents—it was loaned to you by your children.” —Native American proverb