Breastfeeding feels like such a loaded word, these days. It's a word I often feel the impulse to avoid in parties and social gatherings because of the debate it inevitably invites. It seems more and more to belong in the list of words that aren't polite to pull out in mixed company. Interestingly, almost all of those words pertain to women and people with uteruses. Are you surprised?
But it's natural, isn't it? Do people really need help?
Contrary to popular rhetoric, breastfeeding is NOT natural. It's not instinctive for the parent. It's a learned activity. Humans (like other primates) learn by watching others and then copying them. Given how loaded a topic breast-feeding is, and how hidden it has been since the Victorian era (when it was surprisingly publicly acceptable), small wonder first time parents who breastfeed (or chestfeed) have a hard time.
Image source: Pinterest
People don't learn passively. Reading books and blogs and attending lectures alone won't adequately prepare people to nurse their babies. They have to actually do the thing-- there is only so far you can get with positioning a plastic doll in a hospital basement (but you should still go because parents who attend in-person breastfeeding classes have much higher chances of success in reaching their goals).
So where does that leave the parents who want to breastfeed?
That's where the IBCLC (lactation consultant) steps in! IBCLCs have jobs because most humans in industrialized countries have moved away from communal living, and when that communal living ended, so did communal birthing and breastfeeding. Unless new parents are able to attend and access a nursing group, there is a strong likelihood they will spend the majority of their time learning to breastfeed alone, or with a partner or parent who isn't educated in breastfeeding as their primary support. When a parent sees a lactation consultant, they are learning with that person how to breastfeed with their baby, which is the best way to create lasting knowledge.
How much does it cost?
That depends! Prices vary based on a variety of factors: region, clinical setting, education level, and experience level. A brand new IBCLC in a rural area offering office visits might charge $75 per visit and a very experienced home-visiting IBCLC in San Francisco might charge $300. Some charge a different cost for an initial visit than a follow up, and others charge a flat fee.
Lactation consultants in clinical settings can see more people and spend less time traveling between clients (and subsequently have more time during the day to chart and send visit notes to families & their providers), so they tend to charge less per visit. Often, too, insurance companies cover office visits at a better rate than home visits, especially in a physician's practice.
Home visiting provides more individualized care, increased comfort for parents and baby, and an opportunity to learn in the envirmonment where the breastfeeding will primarily take place. However it's time-consuming! Home visiting practitioners usually max out at 3-4 clients per day, factoring in travel time, a fairly average 1.5hr visit time, and overhead from travel like gas and wear and tear on the vehicle. This drives up costs significantly.
Many hospitals offer lactation support inpatient and outpatient lactation, too. The secret that the hospitals don't tell you is that they often lose money after factoring in operations costs, but they can afford to absorb those losses much easier than standalone clinics or practitioners. They are happy to do it, too, because it's often considered marketing, which has a big budget, or public health, which can qualify them for grants intended for large organizations. Hospitals offset costs by hiring dual credentialed lactation consultants (like registered nurses, or, RNs for short) and have them do multiple jobs in addition to lactation, or by shortening visit windows. One local hospital has 15 minute visits.
What about insurance coverage?
Unsurprisingly, private insurance companies want to keep the money they earn in fees. This means they cover only to the exact limits of their policies and no more. The more expensive the policy, the more that's covered. Public insurance companies don't receive much by way of premiums, if anything, so their budgets for coverage are smaller.
Recently, the Affordable Care Act required lactation coverage benefits in most insurance plans. Unfortunately, they immediately found loopholes to that requirement, such as requiring another credential (RN, IBCLC for example). This means the person providing that care may be more limited in scope by having two credentials instead of one.
Timing is another factor for multi-credentialed IBCLCs. An MD, IBCLC has a lot of patients to see in addition to providing lactation care, so it can be difficult for them to achieve the balance of ratios and visit times in addition to their other responsibilities. Having a concurrent credential also means that person is charging a higher fee to cover the costs of their overhead, as well as recoup the costs of their more expensive education.
"Sign here, here, and here. Thanks! We control your practice, now."
Other limitations in insurance coverage are companies refusing to cover home-visiting providers, or denying claims submitted from out of network providers. United Health just faced a huge lawsuit & fines from this exact situation. Trying to bill insurance as an IBCLC is a hit-or-miss prospect. Some companies are covering lactation very well, paying providers up to $400 in reimbursement per visit, while others pay as little as $9. Since this income is so inconsistent, many IBCLCs resort to cash-pay or reimbursement billing via super bills to stay in business.
When an IBCLC agrees to work in-network with an insurer, they allow no bargaining on the cost they are paid per service. They are also bound by their legal agreement to charge everyone the same fee they bill the insurer. If their contracted rate is 40% of their listed fee, that means that the IBCLC has to increase their prices 50-60% than they otherwise would be to make their business sustainable. This drives up the costs that are passed on to the consumer. Many medical facilities get around this by offering a cash-pay discount, but that is intended solely for those who aren't insured, even if their insurance is different than the one with which the IBCLC is contracted. Even so, a cash-pay discount works out the same as the IBCLC would charge in the first place.
Who has $300+ to spend on lactation?
Unfortunately, not a lot of folks can swing the costs. Many IBCLCs understand that and make an effort to provide accessible care with discounted visits for uninsured or low-income families, payment plans, and a majority of IBCLCs will offer free visits at regular intervals for families in dire need. This seems good on its face until you consider that the private practice IBCLC is now working for free-- while incurring the costs of overhead and their day to day costs of living. This isn't a sustainable business model and is a recipe for burnout, if the boundaries in these scenarios aren't kept well-fortified.
People often will make sacrifices to pay for lactation because it is so beneficial to families with the goal of breastfeeding long term. There is so much to learn, it really is best in an individualized setting with baby and partner or support person(s) there with the nursing parent. Many will ask friends and family for help with the costs, or will put the costs onto credit cards or other forms of debt. The interest compounds and it's easy to see why this is one of the most expensive times in a young family's life.
But formula is really expensive. Isn't breastfeeding STILL cheaper?
It's true that formula also costs money (like, a lot of money). In fact, the cost of formula is often used to promote breastfeeding (because breastfeeding is seen as the less-expensive option). This comparison is sort of a logical fallacy, though, because often when a family needs lactation support, formula is needed in addition to the support. It's rarely a dichotomy, so it doesn't really track to treat it like one. Breastfeeding doesn't preclude formula and vice-versa. It also devalues the huge amount of time and energy that breastfeeding entails. Did you know the average parent breastfeeds for up to 60 hours per week? Lactation consultants also cannot guarantee breastfeeding success. Nothing has a 100% success rate. Some parents find they've spent that hard-earned money and still end up using formula or donor milk.
Well, then. I give up! Why breastfeed at all?
This doesn't mean that breastfeeding isn't worth doing! It's still incredibly beneficial to parents and their babies, and is an incredible investment. However, given the climate of medical care in the United States, there are a lot of barriers to care that can't always be overcome by willpower or money or IBCLC alone. Support in the home, society, and the workplace are crucial for breastfeeding success. Lactation consultants can advocate for this support, but systems are hard to change from one angle.
Society sees breastfeeding as something best done behind closed doors, or not discussed. The high rates of failure to meet breastfeeding goals creates divisiveness in parenting circles, as well as systems of oppression keeping people from marginalized groups from receiving the same care their dominant-culture counterparts receive. It can seem daunting to take all of this into consideration, but it's important to present a clear picture of what lactation consultants face on the daily when attempting to promote, support, and protect breastfeeding. Often, IBCLCs take the brunt of the social "blame" because they are the visible representation of breastfeeding infrastructure as a whole.
Aren't they responsible for themselves and the families they see, though?
Definitely. Not being exclusively responsible for the lack of systemic support for breastfeeding doesn't get IBCLCs off the hook. It is crucial that lactation providers undertake cultural bias and humility training, make every effort towards inclusive care, and do as little harm as possible while aiming to support new families in their breast- and chestfeeding goals. Not undertaking this education (that should be central to certification, but isn't, yet) causes great harm to families, especially when one or more members are part of marginalized groups. This is absolutely the responsibility of an IBCLC as a care provider.
Consider, though, that those trainings cost money! In order to provide this adequate care, the IBCLC needs to be able to take the time off from practicing, pay conference or class fees, and implement the knowledge. If an IBCLC is working for free, they're going to be less able to take on this knowledge, which in turn, exacerbates the difficulties facing families in the early postpartum period.
In fact, all of IBCLC training costs money, and a lot of it. The financial and other socioeconomic barriers to the IBCLC credential is a whole other blog post to write. Suffice to say that when an IBCLC is expected to work for free their time and energy are being devalued, as is the expense required to achieve that credential. These costs have to be passed on to visit fees to make the business sustainable. Overhead costs pertaining to any medical (HIPAA-bound) business are substantial. Add inconsistent insurance reimbursement to the mix and you have a recipe for expensive out-of-pocket costs for care.
What can be done?
Parents-as-activists are very effective at generating change! There is no one quite so motivated as a concerned parent. If people would demand better lactation coverage from their insurance companies as consumers, that would benefit them in the long run, too. Insurance companies are businesses, for better or worse, and they respond to consumer demand.
Doctors, nurses, and systems administrators can advocate for better support of breastfeeding across all points of contact with family medical care (and beyond- breastfeeding people visit the dentist, too!).
Politicians and lobbyists can advocate for, and generate change in the scaffolding of support for breastfeeding nationwide. Just don't forget to include IBCLCs and other birth supporters in the conversation, as things can often go awry when breastfeeding is legislated without community input.
This is a complicated and multi-faceted topic. This relatively quick overview is bound to miss some angles. If you have dealt with this, from provider or parent perspective, will you weigh in? What was your experience? What would you add, here?