‘A woman’s business’ requires professional consultants

Breastfeeding may seem the most natural of activities, but certified lactation experts must be highly trained.

baby with mother 311 (photo credit: Ariel Jerozolimski)
baby with mother 311
(photo credit: Ariel Jerozolimski)
Although the Babylonian Talmud tells the story of a poor man whose wife died soon after childbirth and, unable to hire a wetnurse, was miraculously able to nurse the baby himself, breastfeeding is generally a woman’s business. And in almost every case (except a handful of male pediatricians, speech therapists and others in the US who double as lactation consultants), giving advice about breastfeeding is a woman-to-woman business.
Surprisingly, the Health Ministry in Jerusalem has not gotten involved in supervising lactation consultant professionals who, as internationally recognized IBCLCs (international board certified lactation consultants), have to meet rigorous registration standards and even face periodic re-certification. The organization, divided by continent, serves as the “gold standard” in certifying experts in the field.
EARLIER THIS month, International IBCLC Day was marked in Israel by Israel chairman Evi Adams and other members of the Israel Association of Certified Lactation Consultants, along with colleagues around the world. No national events were held to mark the day, but each consultant was free to organize local ones. “We are trying to get official Health Ministry recognition,” said Jessica Billowitz, who came on aliya from the US 18 years ago and has been a certified IBCLC since 2000. “To get certified, you need up to 4,000 hours of training and must pass a seven-hour exam. Re-certification is carried out after five years to make sure the consultants are updated on a regular basis,” she said. Billowitz notes that certification has been in existence around the world since 1985 and that today, there are some 20,000 IBCLCs.
Although recognized globally, IBCLCs are surprisingly not recognized as professionals in Israel. “We are trying to get professional recognition,” she said in an interview. “There are nurses who are nursing counselors in hospital maternity wards and who are paid by hospitals for their job. There are also some salaried inhospital IBCLCs, but women remain in hospital obstetrics and their babies in neonatology units for just a few days. Most of the breastfeeding problems begin when they have gone home,” said Billowitz.
IBCLCs more often work privately via home visits, as lactation consultants are not included in the basket of health services. It can thus cost NIS 400 per consultation.
In addition, there is the La Leche League, which is run by devoted volunteers and by mothers who have experience. In the US, there are midwives who are registered nurses and also work as lactation consultants.
Billowitz explained that IBCLCs stand for knowledgeable and experienced members of the maternal health team who have specialized skills in breastfeeding management and care. But they do not have to be registered nurses or midwives.
THE CERTIFICATION program offers the only credentials in lactation consulting, and is available globally. “IBCLCs have passed a rigorous examination that demonstrates the ability to provide competent, comprehensive lactation and breastfeeding care.
Attainment of the IBCLC credential signifies that the practitioner has demonstrated competence to work together with mothers to prevent and solve breastfeeding problems, and collaborates with other members of the health-care team to provide comprehensive care,” said Billowitz. “This supports, protects and promotes breastfeeding, encourages a social environment that supports breastfeeding families, and educates families, health professionals and policymakers about the far-reaching and long-lasting value of breastfeeding as a global public health imperative.”
Among those who become Israeli IBCLCs are nurses, midwives, dietitians, physicians and experienced breastfeeding support counselors. IBCLCs work in a variety of settings including hospitals, clinics, physicians’ offices, neonatal intensive care units, human milk banks and private practice.
With a focus on preventive health care, IBCLCs encourage self-care, empowering parents to make their own decisions. IBCLCs use a problem-solving approach to provide evidence-based information to pregnant and breastfeeding women and make appropriate referrals to other members of the healthcare team. The IBLCE (the International Board of Lactation board of examiners) has established professional standards for IBCLCs and must renew their certification every five years, either through continuing education or by re-examination.
The training and seven-hour certification exams for IBCLCs are in many languages, with the comprehensive tests given around the world on the same day.
“You can’t just decide to take the exams. There are pathways that make you eligible. Some are already in healthcare professions, others worked in maternal and child health, infant growth and have a background in anatomy, physiology, biology, infant growth and development,” she said.
Lactation counselors don’t have to be mothers, or even be married. They don’t have to have breastfed before.
Some were even unable to breastfeed, said Billowitz, but all are well trained. Women who consult may have started to breastfeed and given up, or not done it at all.
There are women who underwent breast reduction but are counselled on how to nurse babies. Women, she said, want to do the best for their babies. “Consultants come in all ages; many of them are already in their 60s, but there is a new generation as well. Although I have over a decade’s experience, I am one of the younger ones.” Every child, she continued, “deserves the best chance in life.
Guilt is a catchword. Many mothers feel guilty. Women must reach their own goals." IN DEVELOPING countries where water supplies are at risk of infection, even HIV carriers are advised to breastfeed, but in developed countries, the relatively small number with HIV are advised not to breastfeed because AIDS infection from mother to child is almost entirely preventible.
In the Western world, returning to work soon after delivery is common, especially in places like the US.
There is more time to rest, form bonds and breastfeed for a long time in Scandinavian countries, but significantly less in Israel. And once Israeli women go back to work, some have difficulty getting permission to nurse on the job (if there is access, especially a creche on site) or to pump milk.
“Mother’s milk is amazing. It can stay unrefrigerated for eight hours – or even better, be put in a cooling pack and then refrigerated or frozen. It is not esthetic or sanitary to pump in bathrooms, but it can be done in supply closets, storerooms and the like, “and even a friendly boss doesn’t mind his room being taken over for 20 minutes,” she said. Employers are gradually understanding that giving women time to pump milk quietly and securely pays off, as their babies are healthier and less likely to be sick, said the IBCLC. “Even if they look at the dollars and cents of the thing, it makes employees more loyal to their workplaces.”
Weeks before women come back to work, they should try – with professional help if necessary – to pump milk and feed the baby with it from a bottle.
They will find it very stressful if the baby refuses to take a bottle of breast milk. Spoonfeeding is very tiring and frustrating. “But when I counsel women about this from the beginning, it usually works out.”
Billowitz recommends a slow-flow bottle nipple so the infant does not guzzle or choke. Breastfeeding is slower and requires more effort for a baby, but can take as little as 20 minutes, depending on the individual. If they have an ordinary nipple, they can get used to it and get lazy, she said. But all babies should always be held, whatever the source of feeding, and not just have a bottle propped up. It is the best emotionally to have body-to-body contact.
Children benefit from nursing, as there are fewer speech problems because of proper sucking. There is much more known from ultrasound scans, said Billowitz, “as we understand the movement of the tongue and show that it is a different type of sucking.”
Asked about the views of the haredi community, Billowitz said it is generally very positive to do it anywhere, even in public – as long as it is carried out with the mother well-covered. “There always are a few crazies from any sector,” she added. Breastfeeding for a relatively long period saves the family many thousands of shekels in formula, bottles and sterilization costs.
The IBCLC was very upset to hear that when former prime minister Ehud Olmert was mayor of Jerusalem, he was known to turn city council meetings into “an official smoking room” that was actually illegal because they were attended by nonsmokers as well, and that at least one city counselor who gave birth not long before was forbidden to nurse her child modestly during council sessions.
She hopes that breastfeeding, pumping and having baby-friendly workplaces, including a clean place for diaper changing and other activities, should become a norm not only at work but also in shopping malls and other public places. Change can slowly be achieved, she said.
There are some voluntary breast milk banks in Israel – mostly run and the milk supplied under supervision by haredi women – but in the US, prescriptions are written, just like blood infusions are, for babies who need breast milk, which is pasteurized and provided by mostly non- Jewish, healthy women. They are not for profit and located in places like Austin, Texas and Boston.
ALTHOUGH AIMING at more common and longer breastfeeding, Billowitz does not want to make women who use formula feel guilty. But neither does she want to encourage formula companies, who for years have subsidized their supply to newborns in hospitals and openly or surreptitiously given new mothers gift sets of formula to encourage their continued use at home. “A millionaire family’s baby fed with commercial baby formula has a poorer diet than the poorest baby who was breastfed,” she declares.
Billowitz was not pleased by recent ads from a charity organization that gives baby formula to needy mothers without carefully determining whether they could more easily and beneficially breastfeed their babies naturally.
The IBCLC said that while not every mother is able to nurse, if more mothers were informed of lactation care, we would see breastfeeding rates increase. It should be included in the basket of health services.
“But the pressure in hospitals to give advice on breastfeeding is so high; there could be 30 women being advised in a couple of hours. More time is needed at home.” She notes that one health fund, Clalit Health Services, reimburses members, but most of the others do not. There are some supplementary health insurance policies to get additional services.
“I like to see the mother with her baby in a natural environment, so I make home visits. I have helped mothers nurse after having twins, and it can be done even with triplets,” Billowitz said.
Fathers can give bottles of pumped breast milk. It can give women time off to rest. But fathers don’t have to do it, and there are many ways for them to bond with babies, such as playing and giving baths, she advised.
Dr. Lisa Rubin, the US-born gynecologist and obstetrician who a few years ago became head of the ministry’s department of maternal, child and adolescent health is well aware of the fact that lactation counselors in Israel do not meet rigorous requirements and undergo mandatory certification as IBCLCs do. In addition, breastfeeding conditions and recognition of the rights of mothers and their babies are not universal here.
Ministry nursing division head Dr. Shosh Riba issued an official directive last December stating that by 2013, there must be lactation counselling by a registered nurse in every hospital. She also set up an advanced course including over 100 nurses. The ministry has also held shorter courses for tipat halav (well-baby) clinics. But there is the right of “freedom of occupation,” so the ministry has not yet set universal standards and official certification, she said. These courses are significantly less rigorous than IBCLC standards.
Rubin also concedes that the ministry’s Mabat surveys of newborns’ health and feeding are inadequate and cover too small a population group; she can’t even say how many infants are breastfed when their mothers return to work. “No, I am not yet satisfied with what is done; there are always financial and bureaucratic restraints.”
One hopes when the ministry finally catches up and societal changes are established and automatic, the current crop of newborns will not be in high school.