Accessible Care

If you notice my pricing, I have two prices for my services: one regular price, and one if you qualify for WIC.  I've had these price levels for a couple years now, but I wanted to talk a bit about why I have them.  

In the early stages of my career, I came across the idea that IBCLCs spend a lot of time and money in order to achieve and maintain their certification.  Additionally, lactation consulting is a profession that requires knowledge in many areas, clinical skills, and counseling skills.  And so, in this line of thinking, IBCLCs should charge as much as their market will bear.  In my area, that is about $100 per hour.  I thought to myself "Whoo hoo!  $100 an hour!  I'll be making bank!"

Except that is not really how it works.  

As I got further into my career and took on more clients, and watched the clients my colleagues were taking, I noticed a pattern.  By and large, the women coming to see us were upper middle class.  Well, if you know much about breastfeeding statistics, those women had the highest rates of breastfeeding.  It doesn't take much to figure this out.  The women who can afford help have the higher rates of breastfeeding.  (It's not that simple, I know, but the point stands)

IBCLE, the group who certifies IBCLCs, says this in their Code of Professional Conduct for IBCLCs  "IBLCE endorses the broad human rights principles articulated in numerous international documents affirming that every human being has the right to the highest attainable standard of health. Moreover, IBLCE considers that every mother and every child has the right to breastfeed."

How does that align with the idea that we should get paid as much as the market will bear?  In a world where insurance doesn't really cover lactation, it doesn't align.  If we are going to abide by the Code of Professional Conduct, then we can't charge what the market will bear.  It prices out the most vulnerable populations.  If, by some miracle, insurance started covering, or reimbursing all/most lactation services, then sure, price yourself through the roof.  But until then, charging what the market will bear is a direct violation of our Code of Professional Conduct.  

So how do we make a reasonable living, and give access to women who need it the most?  Well, this is my solution.  It's not perfect.  I hope to be able to do better in the not too distant future, and make my prices more accessible.  But this is what I can do right now, so I'm doing it.  And don't get me wrong, I understand the urge to charge more.  I have before.  I'm sure I will again, we all get a little selfish sometimes.  When I feel those urges, I remind myself that doing my best to get access to as many women as I can is the ethical thing to do.  I try to live with integrity, so I choose integrity here.  

"It's normal that it hurts"

I hear and see this all the time.  Women have pain while breastfeeding, they ask for help, and are met with a chorus of "Oh, it's normal that it hurts!"  For many women, it does hurt, but that doesn't make it normal, just common.  Pain is an indicator that something is going on during suck swallow breathe that shouldn't be happening.  It doesn't mean that anything is wrong with the baby.  It doesn't mean that anything is wrong with the mom.  It just means that something has interrupted suck swallow breathe, and commonly it's something that can be fixed!  But not if we continue the notion that pain is normal.  

Suck swallow breathe is a neurobehavioral program.  It's sort of like a very complex reflex.  The baby gets certain stimuli and reacts in a certain way, with certain behaviors and movements.  Cathy Watson Genna and Lisa Sandora have a very thorough explanation of suck swallow breathe on page 3 of Breastfeeding: Normal Sucking and Swallowing.  There are things that can interrupt that program, like intrauterine lie, length of birth, birth interventions, tongue tie, improper positioning and latch on technique, etc.  When the pattern gets interrupted, babies compensate because they have to eat.  Usually, this means they move their tongue, or change the movement pattern of their tongue.  

Let's talk about pain during breastfeeding for a minute.  When women come to me, they usually describe either pinching or rubbing as the pain sensation they're feeling.  The pinching is compression.  That's what gets the white line on the tip of the nipple, or the lipstick shape.  Rubbing is the sandpaper or cat's tongue feeling.  So what's happening that's causing the pain?  The tongue is normally forward, over the lower gum line.  The back of the tongue drops rhythmically during peristalsis to move milk back in the mouth and down into the throat, while the tip of the tongue stays placed over the lower gum line.  When something has happened to interfere with normal suck swallow breathe coordination, the tongue tends to hump or raise in the back in order to slow or change the flow of milk into the throat.  The tip of the nipple goes back to the junction of the hard and soft palates, so when the back of the tongue raises it compresses the nipple.  Ouch!  Similarly, some babies raise the back of their tongues, but the tip of their tongue doesn't stay placed over the lower gum line.  It moves back and forth instead of staying in place and doing the wave motion of peristalsis.  That back and forth motion creates that rubbing feeling.  Also ouch!

So why isn't this pain normal?  Because it means that the tongue isn't in the right position to either seal well, move milk well, or coordinate their swallow.  Those things don't just get better.  Sometimes the pain goes away because the baby gets bigger and stronger and can do less painful things to compensate for the interruption to suck swallow breathe.  The underlying issue is still there, and for some babies it pops back up because they can't transfer milk well and stop gaining well, or when they start solids and have trouble chewing or moving food around their mouths, or even speech issues later on.   

Pain is almost always fixable if it's addressed in time.  There are many ways to help, positioning and latch on techniques are the first line of defense, suck training and finger feeding, craniosacral therapy, chiropratic, and other bodywork, or tongue tie revisions, followed by other therapies for correcting suck issues.  It is important to note that babies tend to stop wanting to do suck training and finger feeding once they hit 3 months.  They get old enough to not really want strangers fingers in their mouths! Understandable, but it makes it a lot harder to fix sucking problems after 3 months.   

Pain is a signal that something isn't right.  It's a signal that something needs to be fixed.  It's usually something that can be fixed.  Let's change the narrative around pain and breastfeeding.  Let's support women in the struggles they're having and help them resolve their issues.  Let's say "I hear you.  I understand.  Let's make it better." 

Meeting You Where You Are

Meeting you where you are.  It’s something we hear a lot about as lactation consultants.  Meet moms where they are.  And it’s maybe one of the most difficult things we are called to do.  Clinical skills, while ever evolving as new evidence and research comes out, are relatively easy to master.  You can read, attend lectures, practice, and you’re set. 

Meeting mothers where they are though, that is difficult.  It means that you first have to figure out where they are.  Are they having a hard time?  Are they conflicted about anything?  Is motherhood and breastfeeding different than they expected?  Is it what they expected, but they are having a more difficult time coping with the change than they thought?  All of those questions that allow you to figure out how each woman is feeling emotionally, mentally, and physically.  Once you figure out where they are, you figure out how to get them from that point to where they want to be.  For some mother’s, that means getting the baby to stop clenching its jaw so it doesn’t hurt anymore.  For others, it means giving them realistic expectations about normal breastfeeding patterns and normal infant behavior.  For others, it means having compassion and empathy and being a safe place to talk about the difficulties that come with being a mother and breastfeeding. 

But lactation consultants are human; we have our own experiences that shape us.  Sometimes, meeting mothers where they are triggers memories and emotions and expectations in us.  That is where meeting mothers where they are becomes difficult.  We are still called to support women, even when it is hard for us.  Keeping some things in mind can make this easier.

-          Each woman’s experience is their own.  It doesn’t matter how difficult their situation is in the grand scheme of things.  It only matters how difficult it is to them.  We can use our knowledge of the grand scheme to help map out how that particular process is likely to go.  But, we should never use that knowledge to judge a woman on how she is reacting, how hard it is to her, or the choices she’s making.  Judgment just drives a wedge between us and the mother.  How is a mother to trust us if we’re judging her?  She can’t, and if she can’t trust us, she’s not going to follow our breastfeeding advice.

-          No one is ever going to make every choice we want them to make.  We’re all different, we’re all going to make different choices, and that’s ok.  Don’t take it personally, don’t judge it.  It’s just how life works.

-          Not everyone is going to make the same choices we made.  It can be really frustrating to be helping a mother who is going through the same things you went through, but is making different choices.  But, we have the gift of hindsight, experience, knowledge, and support. No one has the same life experiences, so even if a mother is having the same breastfeeding problems you did, doesn’t mean she has the knowledge base, support, desires, finances, etc. to be able to make the same choices you did.  That doesn’t make her choices any less valid.  It doesn’t say anything at all about the choices you made.

-          We are just as human as the women we serve.  Sometimes the situations we have difficulty empathizing with are similar to difficult situations in our own lives, either past or present.  Birth and breastfeeding are life changing experiences.  If we had difficult births or breastfeeding experiences, being exposed to them every day can trigger us.  Self care to process through our own experiences can be immensely helpful, both personally and professionally. 

Lactation consulting allows us access to women in some of their most vulnerable moments.  We should use that access to have empathy and compassion, like we all hope we receive when we’re vulnerable.

“Sympathy is easy because it comes from a position of power.  Empathy is getting down on your knees, looking someone in the eye, and realizing that you could be them, and all that separates you is luck.” – Dennis Lehane.  

The Ethics of Lip Tie Revision

Lip ties have been a hot topic in the breastfeeding world recently.  They are the new go-to when breastfeeding issues are not easily resolved.  But, there is no research showing how or if lip ties affect breastfeeding.  If there is no evidence showing that lip ties affect breastfeeding, how then is it ethical to refer for revision?  It’s not.  Here’s why. 

Biomedical Ethics

Biomedical ethics is a field of study dedicated to applying values and judgments to the clinical practice of healthcare.  Lactation consultants have to abide by these ethics as well.  The principles of biomedical ethics are veracity, autonomy, beneficence, nonmaleficence, role fidelity, confidentiality, and justice.  Let’s take a closer look at some of these principles.

Veracity – Veracity is the expectation that both the practitioner and the patient are telling the truth, both actual truth and by not withholding information.  The patient must tell the truth because to lie or to withhold information means that the practitioner does not have the necessary information to make an accurate diagnosis or care plan.  The practitioner must tell the truth because to lie or withhold information means that the patient does not have the necessary information to make an informed decision about their healthcare. 

Autonomy – Autonomy is the principle of ownership.  Patients have the right to choose their care and act on those choices.  Autonomy includes the right to have all the information regarding their care, and that information given in a manner in which they understand.  It also includes the power to act on their decisions.  Having the information about their situation means nothing if they are then not able to choose the care path that they want.  And finally, it also means that the patient must respect the autonomy of the practitioner as well.

Beneficence – Beneficence, as an ethical term, means that the practitioner has a duty to benefit the patient, and do their best to uphold health. 

Nonmaleficence – Nonmaleficence is the expectation that practitioners will do their best not to inflict harm, or minimize the harm, like in the case of side effects for necessary medications.  Nonmaleficence is different from beneficence in that nonmaleficence is not doing harm, while beneficence is preventing and removing harm and doing good. 

Ethics and Lip Tie Revisions

How then do these ethics apply to lip tie revisions? 

Veracity – What truth do we know, via evidence, about lip tie and breastfeeding?  We don’t.  There is no evidence showing that lip tie is a condition that affects breastfeeding, the prevalence rates of lip tie, or if lip tie revisions are correlated with improved breastfeeding relationships.  There is no assessment tool, evidence-based or otherwise, to check for a lip tie.  There is one classification system, but that system does not take function into consideration, and therefore cannot be used as a clinical assessment tool.  Currently, there is no way to assess what visual characteristics and what functional characteristics are involved in lip ties.  So, if there is no assessment tool, there is no research showing that lip ties affect breastfeeding, and there is no research showing that lip tie revisions improve breastfeeding outcomes, there is no way to diagnose or refer for revision while upholding the principle of veracity.

Autonomy – This follows closely on veracity.  In order for the patient to exercise their autonomy, they have to be given the full truth regarding their situation.  The full truth regarding lip ties is that there is no evidence.  Because of this lack of evidence, some practitioners look to their anecdotal experiences and express those as actual evidence.  This is called paternalism.  It is the withholding or limiting of information in order to lead a patient into the decision that the practitioner thinks is best.  It is a direct violation of autonomy. 

Beneficence – How can lip tie revisions be beneficial if there is no evidence showing that they are?  Some practitioners argue that they have seen positive change after lip tie revisions.  Other practitioners, and numerous mothers, report no change.  If the positive change that some people see is so variable, is it ethical to propose that there will be positive change? What about there will probably be positive change?  Maybe there will be positive change? It is unlikely to change?  What is known is that lip tie revisions are not universally successful, and it is not known to what rate they are unsuccessful.  In light of that, it cannot be beneficent to revise lip ties. 

Nonmaleficence – Lip tie revisions are surgery.  They are relatively quick surgeries, but they are surgeries nonetheless.  There is risk involved.  There is pain involved.  Depending on how the specific practitioner performs the surgery, there can be trauma involved.  In other words, harm is done.  Yes, there is always harm done during surgery.  But, the benefits must outweigh that harm.  Do the benefits of a lip tie revision outweigh the harm?  There is no data on the success rate of revision.  If there is no data on the success rate, there is no way to quantify if the benefits outweigh the harm, because there is no way to quantify the benefits. 

Lip tie may very well be a condition that affects breastfeeding.  But, it might not.  Until we have more research, it is not ethical to refer for revision. 

References:

1.      Brooks, E.C. (2013). Legal and Ethical Issues for the IBCLC. Jones & Bartlett Learning.

2.      Edge, R.S. & Groves, J.R. (2006). Ethics of Health Care: A Guide for Clinical Practice. Thompson Delmar Learning.