PRACTISING PRIVATELY IN A DEVELOPING COUNTRY October 2002

PRACTISING PRIVATELY IN A DEVELOPING COUNTRY



1. My name is Pamela Morrison and I have worked in private practice in Zimbabwe for the last 11 years. I suspect that I have the most wonderful job in the world; working as the only Lactation Consultant in a country where breastfeeding is the cultural norm


PART I

I HAD A DREAM .....

2. Late in 1989 two Lactation Consultants came to Zimbabwe to present at a landmark workshop for senior Ministry of Health and hospital staff, which was to mark the beginning of an aggressive and effective national breastfeeding-promotion campaign. One of them told me about her “dream job” as a Lactation Consultant in Europe. Although it had never been done before, and the IBCLC profession, still in its infancy, was completely unknown, it seemed that there might be a gap which could be filled by a an inexperienced, but enthusiastic pioneer. My vision was to address the discrepancy which existed in infant feeding practices between the ordinary African woman, for whom not to breastfeed is unthinkable, and the comparatively small, but hugely influential population of socially and economically-advantaged mothers, the trend-setters of tomorrow, who enjoyed the luxury of accesss to private health care, but tended to experience so many problems with breastfeeding.
3. The IBLCE Exam Board accepted me as a candidate, and were incredibly helpful as I commenced trying to set up the exam in Harare, not knowing if I would be the only African candidate for 1990. Obtaining study and exam materials was something of a nightmare. My first order of books were lost en route from the USA, and then, with only days to go before the exam, the Customs Department seized the booklets and slides, demanding an exhorbitant amount of duty before they would release what they viewed as “educational materials”. The exam itself went off smoothly until the clinical portion, when it was discovered that the young man working the projector had loaded many of the slides upside down or sideways, identifiable in one case only by the direction of the drip-milk tracking along the screen, so that I and my co-candidate, who had arrived unexpectedly at the eleventh hour from Mauritius, were thoroughly unnerved by being asked to leave, five minutes into the afternoon session, while the proctors conferred, the slides were re-loaded and everyone hoped for the best!


PART II

PLANNING

Where to start?

4.The success of my practice has exceeded my wildest dreams, but “floundering around in the dark” was the only way to describe how I set about starting up and and becoming known. There were absolutely no precedents. I knew of no other LC in private practice, and there appeared to be very little literature at that time to guide me. Clarifying how I could work within the healthcare system, and taking care of legal and financial matters seemed to be the most important first step, and then it would be necessary to decide what services I wanted to offer, and where I wanted to work.

My office

5.A small room in my home in Harare was soon converted into an Office, with desk, couch, filing cabinet, baby scales, sterilizer, and shelves for reference books, pumps and other equipment. I bought pillows and linen, towels, wipes and bowls, feeding cups and spoons. Careful thought was given to developing the forms I would need to keep track of my would-be clients’ details, breastfeeding histories and follow-ups. I also developed some tear-off Care Plans for common breastfeeding difficulties, and information sheets on various topics, printed in different colours, to use as handouts. In addition to office consults, I had decided to offer home and hospital visits, so I needed a bag large enough for supplies, but small enough to carry easily. I have since obtained my own computer, which I would recommend to any wanna-be private practice LC as an absolutely essential item.

Legal requirements

6.Clutching my new IBLCE certificate I made an appointment with the Registrar of the Health Professions Council only to be told “you haven’t got a snow-ball’s chance in hell of being registered with us”, but he confirmed that I was nevertheless free to practise. I spoke to a lawyer about legal implications and engaged an accountant. I was lucky enough to find a lady insurance broker who became fascinated by my plans and managed to talk an insurer into providing me with professional liability insurance, even obtaining for me a no-claims bonus at the beginning of my second year, when it became apparent that the practice of lactation consulting did not constitute a major risk.

Being available

7.Being reachable posed something of a problem in those early days. Our phone system is reputedly one of the worst in the world, and I shared a party line with nine other subscribers, some of whom would leave their phones off the hook, clogging up the line for days, and in the rains the whole line would go dead for a week at a time. There was no chance of obtaining a direct line since the waiting list was several years long. Friends of mine, a husband and wife couple who ran a home business, were persuaded to act as my answering service - if my phone went ‘off’ I would collect my messages two or three times a day and find some way to get back to my waiting clients. The husband became pretty good, over the years, at soothing distraught mothers and offering basic breastfeeding tips until I could get back to them. Finally I managed to persuade a sympathetic technician to take pity on my mother-baby clients and speed up my application, and the luxury of having my own direct phone line has still not palled. Nowadays the availability of cell-phone networks in Zimbabwe makes everything easier still.

Reimbursement

8. My husband developed a computerized invoicing system for me, but the question of how to charge clients for consultations was problematic, since I was used to working as a volunteer. I decided to charge slightly less than a physiotherapist, to charge strictly by time, and to invoice each client at the successful resolution of her problem, on the rationale that a client would be more inclined to keep following up with me if she didn’t need to pay cash for every consultation. This has worked well. I often worked with a single mother-baby dyad over several months, often hiring out or selling equipment too, and only invoicing at the end of the problem. What was unexpectedly encouraging was the extremely low rate of bad debts - only two in the first eight years of my practice - which I took as an indication of my clients’ level of satisfaction. The changing economic climate has demanded that I re-think this method of reimbursement and change to a mostly cash basis in order to remain financially viable, but for the LC who wishes to expand a new practice in a strong economy I would still recommend invoicing.

Breastfeeding Aids and Devices.

9. The Lactation Consultant in a developing country may have access to minimal breastfeeding aids and devices. For instance, I have never even seen a hospital grade double electric pump! Nevertheless, the absence of too much gadgetry can be an advantage. Most of the mothers that I work with do not have pumps, so I teach hand-expression and with practice they become very proficient. Nevertheless, I have found that my success in resolving very severe lactation and breastfeeding difficulties has been enhanced by working to access two items which I now consider absolutely essential to have on hand - simple but effective manual cylinder breast pumps, and nipple shields. Sometimes it has been necessary to be very persuasive to businessmen to explain the urgency of these needs, to be inventive in finding outside alternative sources of supply, and to plan and budget for these items far in advance in order to cope with delays in ordering, delivery, hold-ups in the Customs department, and fluctuations in currency values due to scarce foreign exchange.

Marketing

10. .Once everything else was in place it was time to let my target audience know that the services of a Lactation Consultant were available in Harare. Because I wished to be seen as a “professional” I made a conscious decision to follow the example of the other professions in this part of the world, where doctors, health care providers, lawyers and accountants neither advertise, nor actively market their services in any way. So I restrained myself to writing formal letters on my new letterhead to introduce myself and my skills to the best-known obstetricians, paediatricians and general practitioners (family doctors) in Harare. I followed up my introductory letters by making appointments to meet each one in person, taking little stacks of business cards in the hope that they would hand them out to their patients. None of the doctors had ever heard of a Lactation Consultant before (their receptionists always said, “A what?”) and consequently I had no idea how the doctors would react, and I was quite nervous. I described how I hoped to assist mothers with routine and special circumstance lactation and breastfeeding, asking if they supported breastfeeding (who could say No?), or if they had any special wishes in the way I was to work with their patients. I hoped that this would provide them with opportunities to express concerns at the outset, and let them know that I would be careful. It also elicited a surprising range of answers and allowed me to learn more about each doctor and the way he or she liked to work.

11. I did not expect the exceptional level of courtesy, interest and even outright wild enthusiasm with which I was received, often ahead of a whole waiting room full of patients (“This is a fantastic idea!”) I was especially nervous when three of Harare’s finest obstetricians wanted to meet me all at once, but unknown to me, one of them served on the Board of the best private hospital in Harare, and offered to speak to the Matron about the possibility of my obtaining visiting privileges. The Matron made it clear that I was not to upset her nursing staff, but was otherwise happy to allow me to offer lactation consultations in her hospital.

PART III

IMPLEMENTATION

My clients

12. My first client was referred by an acquaintance, and I made a home visit to consult with the mother of a three-week old breastfed baby with “colic”. This was quickly followed by a few referrals from some of the doctors I had recently visited and suddenly there I was, a Lactation Consultant in private practice!
13. I keep a log book recording who I see, and when, also noting the reason, time taken, items of equipment provided, fee, and when paid. In 11 years I have been privileged to work with nearly 3000 mothers and babies, each one absolutely unique and fascinating, and many in situations which have been extremely challenging and demanding. My clients come from all racial and ethnic groups, mostly European mothers of many nationalities, but with a sprinkling of Indian and Coloured mothers, and a growing number of sophisticated African women who increasingly experience the same kind and range of breastfeeding difficulties traditionally experienced by their American and European counterparts. Many of my clients come from neighbouring countries such as Zambia, Malawi, Mozambique, Botswana, South Africa, Angola, and Mauritius to give birth in the good private hospitals in Zimbabwe. They are often highly motivated to breastfeed because of the primitive conditions and paucity of health care in their countries of residence. I also see many expatriate and diplomatic wives, from all over the globe, each with their own special traditions and expectations.

14. In Zimbabwe there is almost 100% initiation of breastfeeding and we now have 39% of mothers still exclusively breastfeeding at 4 months. Most African mothers in Zimbabwe breastfeed for nearly two years. One becomes aware of practices and trends over time. Where many marginally motivated European women used to abandon breastfeeding as they left the hospital (from the middle-income suburbs and farmers’ wives) this group will now often breastfeed for at least the first six weeks before giving up, and in that time some of them get ‘hooked’, generating a ripple effect of longer breastfeeding for a whole group of their friends. An increasing number of my clients are exclusively breastfeeding until 6 months, and many more nowadays are breastfeeding well into the second year of life.

15. The youngest baby I have worked with has been an hour old. The oldest was a 6 year old tandem-nursing with his younger brother. I work with many mothers of twins, and I have even had one set of triplets. Unbelievably, one of my clients only realized that she was pregnant when she went into labour. I work with first-time mothers of 16 and I had another of 42. I assist mothers to breastfeed babies with Down Syndrome, and cleft lip/ palate or other congenital abnormalities. African traditional beliefs about babies who cannot breastfeed make these situations especially difficult for the mother, and thus for the LC. The personal risk of working in an environment where 30% to 40% of all pregnant women test positive for HIV on anonymous sentinel surveillance testing also creates its own difficulties and need for self-care and caution.

16. It has been a special challenge to work with mothers from countries where breastfeeding rates are known to be very low, some of whom have been somewhat disconcerted to discover that the concept of infant feeding choice is unknown in our hospitals, because every mother is expected to initiate breastfeeding and enjoy 24 hour rooming in, and because formula is simply not available for healthy babies. It has been especially rewarding to know that many of these mothers have gone on to breastfeed for long periods, admitting that had they been ‘at home’ they would never have had this wonderful experience.


Referrals

17. Referrals can be generated from several sources:

1) The doctors of your mother-baby clients can be one of your best resources for referrals and information. One of the most important, and at the same time most fulfilling aspects of working as a Lactation Consultant in private practice, is the development of respectful working relationships with members of the medical profession in your community, and the lone Lactation Consultant working in private practice is wise to nurture good relationships with her clients’ obstetricians, paediatricians and general practitioners. After several years I began to realize that some of the doctors were starting to refer clients to me even without having met me first, which is especially pleasing, since it means that my reputation alone has been enough! Being responsible and professional in reporting to doctors, backing up your care plans with up-to-date citations and references, and sharing interesting items of new research with them will enhance your reputation and increase their trust in your abilities

2) From hospital nursing staff. Zimbabwe’s strong breastfeeding policy, and the fact that our paediatricians strongly support breastfeeding for all babies create conditions where hospital nursing staff are, for the most part, already very experienced in assisting mothers to breastfeed. The solo private practice LC in a developing country may find that she is referred clients by nursing staff themselves in three general categories;

• in the extremely difficult situations where the nurses themselves have already exhausted their expertise,

• when the hospital is short-staffed, eg on weekends and/or public holidays,

• where staff perceive that a mother is reluctant to breastfeed and they hope that you can persuade her - this can make for some challenging and tricky situations.

3) probably most importantly, new clients come by the word of mouth from former clients. It is important to remember that each mother you work with has the potential to become your ambassador, with the power to influence the number of referrals you receive many years into the future, since she will tell her relations and friends, and her doctors.

18. I have a space on my clients’ Initial Contact form, to record “Referred by ....” and it can be really fulfilling to hear a new client tell you she was referred by “Oh, everyone! - the Sister at the Clinic, my paediatrician, my sister-in-law who you helped to breastfeed four years ago and my friend with a two-month old....” Furthermore, you may well find that mothers will come back to you with their second or third babies - even if you yourself felt that the breastfeeding outcome with their first baby was not what you had hoped.

LOGISTICS

19. The private practice LC can offer consultations in several different settings, and there are benefits and disadvantages to each:

1) Office consults

I find that working from an office in my home works very well. I can save hours of travelling time by having clients come to me and, depending on my workload, I sometimes do this. Other advantages are that I have all the equipment and information materials I might possibly need close at hand. One disadvantage can be that bored siblings of the nursing baby may range through my office pulling everything off shelves, which both the mother and I find distracting! Another can be that friends or relations will often drop a client off and then abandon her with me way past the time that our consultation has ended, so that I am more or less ‘stuck’ with her until she is retrieved. A third can be that clients often pop in unexpectedly to drop off books, pay bills or just to show me their beautiful babies, and I find it acutely unprofessional, on a day that I anticipated was going to be quiet, to be caught in my caftan and bare feet at 10.30 am! I am lucky to have an excellent male cook/housekeeper in my employ so that I am never alone and thus have no qualms about inviting strangers into my home, but I would imagine that this could be a risk.

2) Home visits

The private practice LC is able to offer one service that perhaps no-one else provides - the chance for a mother to receive tailor-made breastfeeding assistance in the comfort and safety of her own home. Offering this unique service has benefits and risks for the LC. The benefits are that you may get more work by offering home visits, and can make a more realistic assessment of a mother’s individual circumstances and level of support when you see what happens in her home. The disadvantages are that you will use time and fuel to travel to many different locations, (leaving you less time to see more clients) and you need to carry with you all the equipment, forms, and reference materials which you might need.

3) Hospital visits

The solo LC may have an opportunity to make hospital visits by virtue of the fact that she may possess additional expertise or skills which are acknowledged in especially difficult breastfeeding situations. However, it needs to be remembered that you, the LC, run the risk of aggravating potential professional jealousy from the midwives employed by the hospital every time you walk through the door. I especially enjoy doing consultations in hospitals. Approximately 25 - 30% of my work takes place in several of the private hospitals, and occasionally I visit at municipal clinics and government hospitals too. I am very careful to appear to be just one member of the ‘team’. I have learned too, that when I am referred a client by the staff themselves, it is going to be one of those ‘last resort’ things, because they will usually already have done whatever they can to resolve the difficulty themselves. I always make sure to chat to the sister-in-charge, or to the nurse looking after my new client on my way in, listening carefully to the sister’s assessment of ‘the problem’, and then on my way out I let whoever is responsible know what I thought and what I suggested, thanking them for their help. After several years of hospital visiting I was asked to write up my consultation briefly in the patient’s notes so that everyone could be clear about what I had seen, and what I had suggested to resolve the difficulty. This stopped me feeling like a ghost (wafting in and out of the hospitals with no record of my visit ...) and now I take a special note-pad and carbon paper in my tote bag so that I can copy what I wrote up in the hospital notes, and then staple this to my own Consultation form when I get back to my office.

20. Clients first seen in the hospital are mother-baby pairs from 1 - 72 hours post-partum. They are usually experiencing latching difficulties, delayed lactogenesis or may be reluctant to initiate breastfeeding. Sometimes mothers from out of town just want to get off to a really good start before they go home to an isolated farm with little help to breastfeed. Mothers with uncomplicated vaginal deliveries are usually discharged at about 48 hours, though mothers with C/sections or those from far away often stay longer. The paediatricians will not usually discharge a baby until he is breastfeeding well, though often I am used as a back-up, “You can go home if Pam says it’s OK ...” I am always conscious of the huge responsibility in these cases, but I especially enjoy the continuity of being able to assist a mother right from the beginning in the hospital and then being able to follow her up after hospital discharge.

Hospital practices

21. In our hospitals mothers are not expected to exercise a choice about infant feeding; formula is never provided for full-term healthy babies and all mothers are expected to breastfeed. Thus the baby whose mother, for whatever reason, really does not want to breastfeed, is quickly identified, and staff themselves may call on me in the hope that I can change the mother’s mind. This creates a very challenging situation since the mother may state verbally that she wants to breastfeed but her actions frequently physically prevent it from taking place. The baby’s nutrition has to be protected, and there is the expectation from the hospital staff, the obstetrician and the paediatrician that the LC (whose job, after all, is to promote breastfeeding) can fix it! I have worked with mothers who in effect may starve the baby until they can take him home and feed him formula. One paediatrician told me, in a resigned tone, that he knows that these mothers have formula waiting in the car! Things are no easier for the more assertive mother. I have known a Matron in charge of a postnatal ward drop everything to obtain clearance from obstetrician and paediatrician to discharge a mother and twins when it became obvious that the mother intended to bottle-feed her babies in the hospital. The matron stated categorically that she was not having “that” going on on her ward, and arranged for them to go home within the hour!

22. Conversely, I have also worked with a mother of a large baby, who was highly motivated to breastfeed, but who produced no colostrum and whose milk simply never ‘came in’. The baby was discharged home at 6 days, having lost 16% of his birthweight yet the paediatrician had been unconcerned. Needless to say it was obvious that this baby needed urgent formula supplementation once he was home and I was able to follow up until the mother came to terms with the fact that she was one of the rare and tiny percentage who just did not lactate.

23. Another common reason for hospital consults is to assist initiation of lactation, and eventual breastfeeding for preterm babies in the Neonatal Units. The smallest babies I have worked with were twins born at 25 weeks gestation, survivors of a triplet pregnancy, who were finally discharged home from the Neonatal Unit, exclusively breastfed at 100 days of age. Our NNUs may be fairly unique in that formula is only minimally used, on a case by case basis, in tiny amounts for the first 24 - 48 hours, for babies who are well enough to be fed, but whose mothers are not yet producing sufficient expressed breastmilk. Often however, these tiny preterm babies will be on a drip for several days, and then the paediatricians will start calling for mother’s milk, and the babies will go straight on to expressed breastmilk via naso-gastric tube. I may be called to see the mothers of the smaller babies when they want to start expressing their milk, if the milk supply appears to dip below the baby’s needs, and again to assist with positioning when breastfeeding is initiated. Bottles and pacifiers are never used or even seen in our NNUs, gifts of formula are not permitted by law, and any formula used is charged to the mother’s account. Pre-term babies are fed the mother’s own milk, as it comes (with no manipulation of fat content) every 2 or 3 hours depending on their weight. The tiny babies are sometimes supplemented with Vit D but human milk fortifiers are unknown. The baby who has reached 31 - 33 weeks gestational age, and is well enough, will be put to the breast for practice breastfeeds. There will often be a changeover period of some breastfeeding combined with top-ups of expressed breastmilk via naso-gastric tube or by cup/ spoon, but eventually the babies will be discharged at 1800g fully breastfed. Babies who have reached this weight but are not yet breastfeeding are kept until they are, and I see many of these, because everyone wants to go home. Working in such a baby-friendly atmosphere is a real joy, with everyone (mothers, nursing staff, paediatricians) all working towards the same goal - effective breastfeeding for these tiny, at-risk babies. Having the opportunity to facilitate and be a part of the success when these babies grow and thrive on mother’s milk alone, is something that never palls.

Security and other issues for the isolated LC

24. There may be risks to your personal safety, or politically-driven constraints which need to be factored in as you decide whether to offer consultations outside your own office environment. Escalating levels of poverty and unemployment in recent years have caused security to become an important issue in Harare, so that clients may live in mini-fortresses with security guards, electric fences and locked gates, and gaining entry, (and exit) is sometimes difficult. After having a couple of frightening experiences I learned to say No to requests for home visits to certain areas. I also decline outside consultations when the initial phone contact just doesn’t ‘feel right’ and I no longer go out after dark. In addition, incidents of armed robbery and kidnapping on the roads, even in broad daylight, are on the increase. Now that I have a cell-phone I don’t go out without it, and it increases my sense of security if I can phone home to let my cook (my right-hand man!) or my family know where I am. I also often phone ahead to clients to ask them to open their gates promptly, since waiting at a locked gate is known to be a risk factor for being car-jacked. Political tension has also led to work stay-aways, strikes, riots and demonstrations in and around the city. I have learned to look out for rioters, or truckloads of armed riot police, and to do fast U-turns. The irony is that the worse the unrest, the more your clients need your help to breastfeed their babies! During our worst fuel shortages I re-arranged my time, taking my lap-top plugged into the cigarette-lighter in my car so that I could read my email while sitting in fuel queues, often lasting 5-6 hours from 4 am. I also limited home or hospital visits to times and places where I could easily combine them with collecting my boys from school, but was once persuaded by a desperate father to make a hospital visit in exchange for a full tank, to our mutual benefit. Allowing a total stranger to drive away in my car seemed a little risky, but after all, he had trusted me with his baby!

Teamwork

25. There is a special challenge in working to meet your client’s need to initiate or preserve lactation or breastfeeding, while simultaneously working along with hospital policies, and with what your clients’ obstetrician and paediatrician have ordered. Sometimes there are other health professionals involved as well; at different times I have had to work with a cardiologist, a neurologist, a psychiatrist, psychologists, orthopaedic and plastic surgeons, an orthodontist, physiotherapists, dentists, anaesthetists and intensive care unit specialists (for mother, or baby) some or all of whom have an interest in an aspect of the mother’s or baby’s health which can compete with lactation or breastfeeding. The Lactation Consultant who is able to work as one of a team, with the mother’s and baby’s best health outcome as the main goal, will be rewarded by being treated as a professional.

Typical day

26. I enjoy the flexibility of being able to choose my own working hours, enabling me to work around my family’s needs. I usually see between 2 - 4 mothers per day, and I also receive phone consults and make follow-up calls. The volume of work is very up and down, and nearly always unpredictable. One day is quiet and then there will be days when everyone seems to need you at once. For instance, I had no work at all on Friday, I made two hospital visits on Saturday, and received one call at 7.30 pm from an out of town mom on Sunday. I am almost never booked up much in advance, and this Monday morning my diary showed an absolutely blank day. But, as often happens, today turned out to be one of those days and my morning went like this ...
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6.23 am Call from a grandmother of a 4 day old baby at home, requesting a home visit for the mother, arranged for 11 am. It turns out that this is a former client, seen with her last baby, 5 years ago.

6.40 am Download email. Of special interest is a message from someone in Australia about an
upcoming Codex meeting in Berlin, commenting on whether labelling of weaning foods
should state from four or six months, and an astute message from an LC in the USA on
the HIV and breastfeeding list. I leave the LACTNET messages to read later, when I
have more time.

7.15 am Follow-up call from a mother of another 4 day old, seen in the hospital on Saturday for a
latching difficulty (tongue-sucking). Mom wants to let me know that the baby is now
breastfeeding for 20 minutes at a time every 2 1-2 hours, and now she is afraid of getting
sore nipples. Long discussion what a success this is, and how to avoid/treat nipple soreness.

8.00 am Call from an African mother who attended my last ante-natal class. Baby is 6 days old. Mother has one engorged breast and the nipple is ungraspable. We discuss whether mom is able to hand-
express (taught at the class), but she is undecided whether she would prefer a breast pump.
I suggest that this needs to be resolved promptly, (drainage by manual expression, cabbage) and offer office consult later in the day if she is not managing. She will get back to me.

8.30 am Call from Sister-in-Charge of the postnatal ward at the largest private clinic. She requests
a hospital visit for one of the patients. When I speak to the mother herself I find out that she is very young (only 16, white Zimbabwean by the accent) her baby boy is one day old, and a healthy 3270g, but is not latching to the breast easily. I ascertain that she would prefer to bottle-feed. Oh dear. I advise that the hospital will not provide formula, discuss cost of formula feeding, suggest that she consider breastfeeding for now, take her paediatrician’s advice (I know he will recommend breastfeeding), and get back to me if she would like me to make a hospital consult to show her how to resolve the latching difficulty.

9.15 am Call from out of town mother. Her exclusively breastfed 3 week old is gaining weight well, but
feeding for short times at short intervals. Mother has formed unrealistic expectations and has
been trying to “structure” baby’s sleep/feed intervals in accordance with guidelines set out in
a popular (detachment-parenting) baby-care book. This is a highly organized, intelligent mother,
so we discuss recent research on breastmilk synthesis and gastric emptying times, and she is
reassured.

10.00 Call from second-time mom of another 3 week old. Baby is gaining well, spitting up, has blocked
nose, writhes around and seems uncomfortable. Explore possible sensitivity to bovine proteins
ingested by mother, what to expect.

11.00 Home consult arranged earlier in the day. Third baby, 3 days old, somewhat jaundiced, sleeping long periods and difficult to latch in cradle hold, has receding upper gum and high palate. Mother has moderate breast engorgement. Review how to use own pump, and latching techniques in football hold; baby sucks well, suggest breast compression during nursing to increase intake, feed 50 ml EBM every 3 hours if baby not alert enough to breastfeed, see paediatrician if jaundice spreads to arms
and palms.
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PART IV

FINDING SUPPORT AS AN ISOLATED LC


Keeping abreast

27. One of the most difficult problems of being an isolated LC is obtaining access to good, up-to-date information on lactation and breastfeeding. Having no-one to ask means that you will need to be able to access written information. There are two aspects to this;

• knowing what reference materials are really worthwhile to obtain,

• knowing where to locate information on a particular topic again when you need it once you know you’ve read it somewhere!

28. Publications written especially for the lactation community, such as the Journal of Human Lactation, Breastfeeding Review, Breastfeeding Abstracts and ALCA Galaxy, and the annual reading list for the IBLCE exam, are all good sources of information about the materials I need to have on my bookshelf. Obtaining these materials has been a particular challenge, since our foreign exchange regulations limit how many and what kind of books and subscriptions I am able to order, and the value of our dollar, and the cost of postage makes them prohibitively expensive. LC friends and colleagues overseas have often overwhelmed me with their generosity in sending me their older editions of vital materials when they update their own libraries, and I have placed a priority on obtaining books and journals in my own budget.

29. While studying for the IBLCE exam in 1989 I soon became overwhelmed by the vast quantity of information on lactation and breastfeeding that was available even then, realizing that I would never be able to remember it all! My husband suggested a way of keeping track of information by topic which I have used ever since. I obtained tickler boxes and stacks of cards and jotted down information by subject (which was also a great way of studying) noting down where to find it in my reference books. I filed the cards alphabetically so that I could easily look up the topic again. I call this set of little boxes, marked ‘A-E’, ‘F-O, ‘P-Z’ my “Brain” because I couldn’t do without it! If I want information for a mother with a nipple bleb I can look up “BLEB” (also cross-referenced under ‘NIPPLE BLISTER’) and find a good description in Breastfeeding Review, July 1991 issue, page 118-9. There is more in Breastfeeding Matters page 161, the Breastfeeding Answer Book page 174, and Breastfeeding and Human Lactation, page 387. Whenever I receive a new journal I note down information of interest in my Brain so that it is continually updated. This system saves me hours of time whenever I encounter a rare problem that I know I’ve read about somewhere (but where?) or whenever I want references from the literature to share with a doctor.

Keeping notes

30. One of your best assets will be your own experience. A lone LC does not enjoy the luxury of being able to discuss case histories with colleagues, but as your number of clients grows you can learn from your own experience, carefully recorded in your own notes. Keeping full, comprehensive notes of anatomy, history, care plan and outcome can provide you with an opportunity to see what works and what doesn’t, can force you to think through each situation carefully, and provide an easy-to-follow record of each client’s progress. I open a folder for each client, starting with Initial Contact and Initial Lactation Consultation forms, and drop notes of each subsequent contact, and any reports, into the file as they occur. I have an archive system so that I can pull a client’s file months later, for the same baby, or even several years later when she comes back again with a third baby, which provides me with anticipatory guidance when working with this client again.

31. I also have a box file marked ‘Case Histories’ where I record details of very unusual or difficult situations, including client’s name and when I worked with her, so that I can look up the whole file if necessary. Case histories are filed alphabetically by subject, eg ‘ABSCESS’, ‘IMPERFORATE ANUS’, ‘LARYNGOMALACIA’, or ‘RABIES’.

Developing a support network

32. One of the biggest challenges of working as an isolated LC is the loneliness of not having a colleague who speaks your language, nor of having any way of measuring the success of your practice. Thus finding ways to maintain contact with other Lactation Consultants, albeit at long distance, can be vital for your own support, in order to keep abreast of current trends, and to keep up to date with what is happening in the wider world. Being an ILCA member will be helpful. Many countries have ILCA affiliate groups, and joining the one nearest to you can help to keep you in touch. Many ILCA affiliates run a sister program whereby a group may “adopt” a lone LC. I will be forever grateful to the US group that adopted me, and helped me financially by paying my ILCA subscriptions when doing so was so difficult from Zimbabwe, by writing and sending me their newsletters and personal notes, and by allowing me in the first lonely years of my practice to write them long letters picking their collective brains!

33. As an extremely isolated LC, the single biggest change for me occurred when I discovered email. After working for several years alone, and feeling as if I was blind, my LC life and outlook were completely re-vamped by finding LACTNET, an email list of over 2000 lactation professionals from all over the world, and subsequently having the opportunity to join an email list for Lactation Consultants in private practice. Email is like a lifeline, enabling me to keep in constant contact with colleagues and professional friends, to learn so much, to contribute to professional journals and international debates on breastfeeding issues, and allowing me to participate in the international breastfeeding arena even at this distance.

Mentoring and professional networking relationships

34. It is also adviseable to try and form a mentor relationship with a local paediatrician and an obstetrician whereby you can ask for education and information on medical matters which you suspect may impact lactation and breastfeeding. In return, these health professionals may ask you questions for their patients. I sometimes gladly see my friendly paediatrician’s government hospital patients at no charge, firstly as a way of expressing my gratitude for his help to me, and secondly because the breastfeeding problems are always extremely severe, the babies very wasted and sick, and I find them especially challenging and rewarding to work with.

Emergencies

35. The LC in private practice is likely, sooner or later, to find herself in the middle of an emergency situation by virtue of the fact that the mother-baby dyads she sees will be out of hospital and may not yet have sought medical advice for a health problem. Your assessment of a mother’s or baby’s ability to breastfeed can reveal a need for further medical care. Furthermore, the LC who spends an hour or more in the company of a mother-baby pair may be in a position to observe a problem which a quick doctor’s visit may not have picked up. I have been the first person to know that an 11 day old baby was 30% below birthweight, and that a preterm baby remained 20% below birth weight at one month of age. I have urgently referred back to their paediatricians babies with undiagnosed imperforate anus and undiagnosed congenital heart defects, and an extremely jaundiced 8 day old whose total serum bilirubin was shown to be 28 g/dL. I have also had a baby in my office having convulsions which a family doctor had attributed to “colic” on the basis of the mother’s description. The baby was subsequently found on CT scan to have fairly severe brain damage. A lone LC does not have the benefit of being able to confer with colleagues about these worrying situations. At times like these it is vital to know how you can reach your clients’ doctors in an emergency. For your own protection, ensure that you are covered by insurance, and as soon as possible afterwards make extremely detailed notes of all that you observed, what you suggested, what was done, and who you referred on to.


Outreach

36. A unique opportunity exists for the lone LC to increase her own range of experience and enhance her visibility by assisting general breastfeeding-promotion efforts in her community, or even on a national scale. If you are the only lactation professional in your area or country, consider offering your services to people or organizations who might need them. You may, or may not, get paid but a gift of your time and talents to promote breastfeeding can make you more widely known and often has unexpected bonuses. I have had the opportunity to help set national policy on breastfeeding by serving on our national multi-sectoral committee for nearly a decade.

37. I have also had the very rewarding experience of contributing to the Baby-Friendly Hospital Initiative in my country as a trainer/facilitator at BFHI workshops for healthcare staff, as a BFHI Assessor in government and municipal hospitals, of which Zimbabwe now has 46, and finally as a member of the national BFHI Task Force. BFHI Assessments have provided some wonderfully heartwarming and uniquely African experiences; interviewing new mothers and realizing that none of them knew what teats and pacifiers were, being able to award 100% score to a male laboratory technician who clutched his white coat to his chest to give a perfect example of manual expression of breastmilk, having the chance late one night to observe a newborn baby girl crawl up her mother’s abdomen and self-attach to the breast while an overworked midwife had to choose between assisting with the first breastfeed or searching frantically for mislaid sutures; being able to slip in an extra assessment for a crestfallen male security guard, missed in random sampling, who had been through all the training and was dying to show off all his breastfeeding knowledge “in case the mothers need help with breastfeeding while they are waiting in the queue at the gate”. Possibly the greatest highlight though was finally being able to teach staff at the hospital where my own babies had been born 20 years ago how to be ‘baby-friendly’ and then assessing them later to make sure!

38. It has also been extremely satisfying to officially monitor industry violations of the International Code of Marketing of Breastmilk Substitutes, and then provide input towards, and haggle with industry over the provisions of national legislation which was finally passed through parliament to give effect to the Code.

39. I have blatantly ‘pushed’ breastfeeding by offering talks to high-school students, on the rationale that within 5 - 10 years these young men and women will be parents and these have been immensely fulfilling. The most challenging questions I have ever been asked have come from these audiences. I have also been the guest of a dozen radio or TV talk shows and phone-in programmes to share my fascination with the subject of lactation and breastfeeding and these, too, are really fun to do.

Special interests

40. A phone call from a distraught mother six years ago sparked my current special interest in the on-going international debate on the thorny issue of whether HIV-infected mothers should breastfeed. In turn this interest led to a related issue; the question of human rights and breastfeeding. Work on these issues resulted in publication of several articles and letters and subsequent invitations to participate at meetings and conferences in countries as far away as Australia and Brazil where I have met some of the finest minds in the lactation world.

Politics

41. Being a member of a minority racial group in Africa requires sensitivity to local cultural practices and traditions, some of which are beneficial to breastfeeding and some of which are not. The LC who wishes to give a little of her time to breastfeeding advocacy work will eventually become aware of the political alliances and heirarchies which exist in her community, or country, and it requires a certain degree of skill, and something of an instinct for self-preservation, to work in and around the very sensitive areas where there is often a hidden agenda. I have found that the best way to skirt this professional minefield is to keep my focus firmly on what I am working to achieve, which is to help the individual mother breastfeed her baby for as long as possible, and as far as I am able I make it clear that this is what I am working for, and that I will work with anyone else who has this same goal.

42. When working in a country where there is war, conflict or civil unrest it becomes very obvious that the needs of mothers and babies cut across all racial, ethnic or political boundaries. Recently my clients have included the wives and sisters of those whose names may have appeared prominently in negative press reports, and those who are the victims, for instance the farmer’s wife who thought she had lost her milk the day after she had been given 2 hours to pack all her worldly possessions into two suitcases and flee for her life with her baby, as well as others whose homes are surrounded by ‘invaders’ or have been actually taken. But their mothers experience identical difficulties in breastfeeding them, and the background of politics, lawlessness and mayhem is of no consequence as I work with this mother and this baby to help them breastfeed.

Avoiding burnout

43. The lone LC, by virtue of her isolation and lack of support, is at risk for burnout in any situation involving stress or distress. This might be when the baby of one of your clients dies, if you are over-extending yourself by taking on too much, or if you have stressful situations within your own family. It is important to know whether continuing to see mothers when you yourself are distressed affects the quality of the assistance you provide, and act accordingly. I find that I completely forget about my own stresses the minute I start taking a client’s details, and become caught up in the fascination of finding out what it is that she needs in order to be able to breastfeed her baby, and for me time spent during a consult is almost like a personal emotional holiday. One exception was when my son was charged with a serious crime after a car accident. Justice prevailed and he was eventually acquitted, but I was such a basket-case that I knew I would have to avoid consulting on the days that he had to appear in Court.

44. When you are the *only* LC around, it is difficult to say No when too many people need the assistance and skills that only *you* can provide, or when you are trying to work on many outreach projects while still keeping your private practice going. I have learned that I can comfortably see no more than four clients in one day if I am working on other things as well, although I can just squeeze in about eight if I have nothing else on. If I am attending all-day workshops I sometimes arrange to see clients very early or very late in the day but this can be so exhausting that I can’t do it for more than two days in a row. If you are also writing articles or critiquing others’ work and trying to meet too many simultaneous deadlines it is tempting to work until late at night and become very tired. Having fallen prey to a mystery “virus” which nearly killed me two years ago after I had stayed up until the early hours of the morning for several months running, and having been prostrated for six weeks as a result, I have learned to pace myself, to stop when I become tired, to be choosy about the tasks I take on, to deliberately schedule time for family, friends, relaxation and just to ‘smell the roses’.


PART V
EVALUATION

Reviewing what it takes

45. The solo LC in an isolated setting, while facing many constraints and difficulties for which there are no easy solutions, has the opportunity to to work as creatively and imaginatively as she wishes, to put her unique stamp on whatever she achieves, and to make it by her own efforts alone. There is almost no end to the opportunities for the LC who is prepared to

• invest the time and energy to give each client 110%
• plan carefully
• do the paperwork and keep up to date
• nurture her sources of referral
• give a little time to outreach in her community, and/or internationally

The realization of a dream

46. I had a dream of working professionally in private practice to help more mothers breastfeed, and for longer. I dreamed of doing something that I love, and being paid to do it. Not only has that dream has come true, beyond my wildest imaginings, but the realization of it has turned out to be a stepping stone to an even wider world.



Pamela Morrison IBCLC
Lactation consultant in private practice
10 Camberwell Close
Harare
Zimbabwe (1990 - 2003)