Thursday, 24 May 2012

IBCLC vs CLC - which is better? Why are we asking?

Emily at Anthro Doula just completed her Certified Lactation Counselor (CLC) course (congratulations!) and in her post on what she learned, she pointed to a link to a position paper by the organization that runs CLC training, Healthy Children. The position paper essentially argues that the CLC and IBCLC are equal credentials and that there is no "hierarchy" in lactation credentialing. I have seen this as a hotly discussed topic among IBCLCs, CLCs, and doulas recently - online and in person - and reading the position paper made me really want to get my thoughts down on this.

There are a lot of arguments about which training/exam/experience turns out better lactation professionals, or whether one is guaranteed to turn out better professionals that the other. There are CLCs out there arguing that CLCs can be just as qualified as IBCLCs to help breastfeeding moms. There are IBCLCs who argue that the training and credentials of IBCLCs are superior and that mothers should not count on CLCs for certain kind of breastfeeding help. The comments sections of the second post engages in some debate, so read up if you want to familiarize yourself with some arguments on either side.

On the question of who is the more advanced support for breastfeeding and who receives the more advanced training, my answer is unequivocally IBCLCs. I did a training very, very similar to the CLC training when I was training as a doula. It was a slightly shorter course, but otherwise it had many of the features that the CLC's position paper favorably compares to IBCLC training - competencies testing, written exam, dozens of hours of classroom teaching, etc. It was a FANTASTIC training! I learned so much, and still use some of the skills I learned there today. I went on to help a lot of mothers and babies breastfeed; I think I did about 40 hands-on consults in the following year. I had what some CLCs feel makes them comparable to IBCLCs: training and experience. I puttered along happily with that training for years, feeling capable of handling a lot of breastfeeding questions.

Then I did IBCLC training. I am here to tell you that there is no comparison between a CLC-level course, and a Pathway 2 IBCLC course. How can there be, when in Pathway 2 you spend hundreds of hours hands-on with a clinical mentor? There was so much I learned from my mentors, a lot of mistakes I made that they were able to correct, and a lot of time to soak up knowledge and techniques. Could I have gotten there on my own by trial and error, via experience as a green CLC? Probably - I had to make some mistakes on my own anyway when my training was over, because making mistakes is an inevitable part of learning, in any profession. But let me point out that when we make mistakes to get experience, we are making them by working with mothers and babies who may have more difficulty breastfeeding, health issues, and emotional pain because of our mistakes. Shouldn't we do our best to minimize the number and impact of these errors by setting up mentor relationships, much as other health professions like medicine, midwifery, and nursing do for their trainees and new graduates?

(The one place where the CLC might get traction with me in this argument is in the issue of Pathway 1, which I have also written about before. I think this is an area that IBLCE will need to address in the near future - the fact that individuals with another clinical degree do NOT need mentored hours - although they do have many hours of hands-on experience. I think it's problematic that someone with no other qualifications can become a CLC without ever doing hands-on clinical work and then promote their services. I think it's also very problematic that someone with clinical qualifications can become an IBCLC without ever MEETING another IBCLC. Those IBCLCs are missing out the same thing that a CLC is - mentorship and hands-on training.)

So no, I don't think Healthy Children, or CLCs - especially new CLCs - should say that IBCLCs and CLCs have equal experience and training to offer to mothers. Does this mean that if I took the best CLC in the world and compared her to the worst IBCLC, that individual IBCLC would still be better? Probably not. As this post points out, there are some really bad IBCLCs out there, and great CLCs. There are likely also CPMs out there who give better, more evidence-based counseling and treatment to their clients for gestational diabetes than do some OBs, even though OBs are supposed to be the experts in high-risk pregnancy. Anybody can be good or bad at something, regardless of the letters next to their name. But I will certainly argue that the overall average experience and range of IBCLCs exceeds that of CLCs, and I base this in large part on the fact that I've done both kinds of training and lived the difference. There is no way that new CLCs can handle 95% of breastfeeding problems and that the rest require advanced, non-lactation interdisciplinary support as this post claims - I can't handle every breastfeeding problem without calling on more experienced IBCLCs for help and guidance, and I've already been an IBCLC for two years (and no, it doesn't need to rise to the level of needing outside specialties to need some extra guidance.) In fact, I felt MORE confident and independent BEFORE I did the IBCLC training - because I didn't know what I didn't know.

BUT - until we get IBCLC licensing in the U.S. (which I am excited about and seems to be moving forward on many fronts) the question is to some extent academic. Anyone can advertise their services, and any CLC can say she's equal to an IBCLC without legal repercussions. The debate is mostly lactation-world infighting and it's questionable whether, apart from potentially convincing CLCs not to advertise their services, it will really benefit consumers (unless there are a lot of sleep-deprived new mothers out there researching the issue on the internet before they decide whom to hire). I think the more interesting issue raised here is access. I've written about how financially and logistically impossible IBCLC training is for many people to attain. People who get bitten by the breastfeeding bug fall hard - I know, I got bitten myself. You end up searching and searching for ways to do what you love - helping moms and babies - and all the routes to an IBCLC seem closed. I would brainstorm ways to make it work at various points in my life, before giving up again upon realizing there was no way I could get the clinical hours. The CLC, on the other hand, has brilliantly positioned itself as a way to be "like an IBCLC" without all the impossible requirements, not to mention the financial investment in IBCLC training that is so difficult to recoup. It is unleashing a group of people who so deeply want to do this work by giving them a credential they can feel is "close enough" to enable them to pursue that passion. Should we be surprised that CLCs are such vocal defenders of the certification, that Healthy Children is investing so much in legitimizing it, or that people sign up in droves?

But it is troubling to me, because what we need is not to make a lactation consulting credential that is more accessible because it's quicker and cheaper. We need to make a credential that is accessible because lactation consulting becomes a profession that will pay off in the long run through reimbursement and greater recognition, and because it is offered through formal educational programs. This would enable the credential to become more rigorous, not less, which I believe is the way the field needs to go.

In short, I think in a better world, we wouldn't be asking which is better, IBCLC or CLC. No one would be battling to prove that they could do consults with a CLC credential, because the people who wanted to do consults would be able to become IBCLCs. The CLCs could happily go on doing basic breastfeeding support, education, etc. - which is a great role for that credential to play.

Thoughts? Any IBCLCs and/or CLCs out there want to give their perspectives?