Episode 1: Who Gets to Define Good Care? With Christine Staricka, IBCLC, and Olena Dobczansky, RN, IBCLC Please Follow the Show, Leave Us a Review on Your Favorite Podcast Player, and Share It With A Friend! Supply and Demand is a weekly miniseries examining the promises, power, and business of perinatal care. Yes, we know: neither of us likes the term “supply.” Here it carries a second meaning. This series is about the value of care: who provides it, who pays for it, who profits from it, and who answers for it. In Episode 1, we start with the foundation: who gets to define good lactation care, and how has our own understanding of it changed over decades of practice? The four lenses for this seriesEach episode is grounded in four questions: * Ontology: What is the object of care? What, exactly, are we caring for? * Epistemology: How do we know what is happening? What tells us care was successful? * Ethics: To whom is the clinician accountable? * Economics: What is the value of relational care, and what does it actually require? In this episode * (00:06) What we each understood our job to be when we started. Christine was taught to protect three things: the mother, the baby, and breastfeeding. Lose one and the stool falls over. Olena came to lactation as a pediatric RN and describes how long it took to see the dyad as a relationship rather than two patients. * (00:10) Systems versus the care in front of you. Insurance billing, scheduling, no-show policies, and charting templates are built for managing care en masse. Many solo practitioners are uncomfortable with gatekeeping, and that discomfort has a cost. * (00:13) The dyad has no chart. There is no “dyad note.” When the system documents only one half of the relationship, it shapes what clinicians believe they are responsible for. That is ontology in practice. * (00:16) “Lactation consultant” is an unregulated term, and it doesn’t tell families what we actually do. * (00:18) How do you know care worked? Is the measure dropped shoulders, objective findings, or the absence of phone calls? Most lactation clinicians get almost no feedback unless a system exists to capture outcomes. Olena’s advice: you don’t need a big network, you need one colleague who will pick up the phone. * (00:20) Where does responsibility end? A patient reports a symptom or a knowledge gap. Is “educated on responsive feeding” the end of your obligation? Does the answer change between the hospital and a home visit? (00:25) The only meaningful definition of good care is what it means to the person receiving it. * (00:27) Data without meaning. Exclusive breastfeeding rates and pumping volumes matter only when they connect to care and to what the family wanted. * (00:30) Tracking apps, infant data, and surveillance. Who receives the data parents enter about their newborns, and why is the perinatal population such an attractive target? * (00:32) Medicalization and fragmentation. Birth was systematized for scale, and lactation support is following. Now there are multiple experts, apps, and devices, and the mother no longer owns the experience. * (00:35) Accountability and advice. A clinician with a client relationship is responsible for outcomes. A social media account telling thousands of people what to buy is not. * (00:36) Pump companies and the formula playbook. Responsibility is shifted to “how it was used.” Instructions move online. Industry presence at professional conferences buys favor. Product education still requires a clinician to interpret it for the person in front of them, and that interpretation is why we exist. (00:42) The opposite of what the American Lung Association is doing. Respiratory health organizations are telling the public to talk to a human. Perinatal health has moved toward bots, apps, and venture capital. * (00:44) Economics. One consult, one payment, no relationship: what can you actually accomplish? What is the bare minimum required to provide care at all? * (00:47) Hospital lactation care. Episodic, interrupted feeding teaches families that breastfeeding happens at “feeding times” rather than as a lived relationship. There are de facto discharge pressures even in Baby-Friendly hospitals. Hospital IBCLCs often have no authority over lactation. * (00:52) A $750 sleep consult. Why does every lactation fee get scrutinized while other perinatal services do not? * (00:55) Cognitive dissonance and moral injury. Many lactation consultants change practice settings because they can no longer tolerate the gap between what they know and what the system allows. * (00:59) Is a consult care? A one-time surgical consult and a home lactation visit share a name. They are not the same thing. Reflection questions * When you entered practice, what did you understand your job to be? What has changed? * How has your understanding of good care changed through experience, and how does it shape the care you provide today? * What do you need to see before you call care successful? * Who do you call when you need to talk a case through? * Where does your responsibility end when a family follows your advice and the problem persists? Join the conversation However long you have been in the lactation field, we want to hear what you’ve seen. Reach out about joining us on the podcast by Hitting Reply to this email. Disagree with us, especially on the term “lactation consultant”? Tell us why in the comments below or connect with us on LinkedIn. Mentioned in this episode * D.W. Winnicott and relational/psychoanalytic approaches to the parent–infant relationship * Listening to Mothers survey series (Childbirth Connection) * American Lung Association guidance encouraging people to consult humans rather than chatbots for respiratory health questions Stay Tuned for our Next Episode: What Does a Credential Promise? Subscribe to get this delivered straight to your inbox This is a public episode. If you would like to discuss this with other subscribers or get access to bonus episodes, visit ibclcinca.substack.com
