The Conception and Birth of the Lactation Consultant Profession (1977–1983): An Interview With Chele Marmet (Part I)

Chele, how did you first become interested in breastfeeding?

When I was 9, my mother “banished” her visiting friend to my bedroom to feed her 2-month-old baby. I had no idea why anyone had to leave the camaraderie around the kitchen table to feed a baby in a bedroom. Until that time, I had only observed babies being bottle-fed. After I showed her how to get to my room, she invited me to stay and keep her company. Although we talked the whole time she breastfed, I watched their continuous silent communication—through their eyes and body language. It was gorgeous! I immediately knew babies were meant to be breastfed and that I would breastfeed my babies.

My next exposure to breastfeeding didn’t occur until I was 22. I had just returned to Saint Louis from 2 years of living in Tokyo, Japan, when my cousin, Francine, invited me to accompany her to a La Leche League (LLL) meeting in August of 1966. After that meeting, I had no further exposure to breastfeeding until I put my first baby to my breast in August of 1968. I experienced the usual problems common to that “era”—separation from my baby after birth, which led to engorgement. My baby requested frequent feedings, which my mother and grandmother insisted meant I must not have enough milk. Thankfully, my breastfeeding-experienced cousin’s advice, “Just keep breastfeeding,” got me through all those early problems. After that, my baby breastfed well until she self-weaned at 9.5 months.

My second baby, born 17 months later (February 1970), and my third (June 1973), were a huge breastfeeding challenge because of an anatomical nipple anomaly (that I later labeled a dimpled nipple—not inverted), which caused pain and bleeding. To this day, I’m not sure why the dimpled nipple did not cause pain with my first, though she did spit up blood one time, so I clearly had the problem with her, too.

Breastfeeding women turned to you for help; how did they find you?

It is hard today to imagine the late 1960s and early 1970s breastfeeding desert (U.S. Department of Health, Education, and Welfare, 1979; U.S. Office of the Surgeon General et al., 2011). In 1968, I did not know even one other person currently breastfeeding in St. Louis, Missouri (the large, Midwestern U.S. city where I was born, raised, and lived). Consequently, it was unsurprising that at 3 months postpartum, when I was breastfeeding my first child, word had spread that I was “a very experienced breastfeeder.” From then on, I got calls for help from all over the country. They found me by word of mouth. I never sought it out, advertised, or charged money for my time. I willingly shared the knowledge, albeit very limited, from my babies’ tutelage, my formal education, and previous experiences from all the dyads with whom I had worked. When I did not know how to help mothers over the phone, I invited those who lived within driving range of my home for an in-person visit with their baby, in the hope that I could provide better help.

In what ways did your undergraduate degree from Washington University’s (St. Louis) Central Institute for the Deaf (CID), in speech and hearing, contribute to your success during these early days working with breastfeeding mothers?

My education at CID greatly enhanced my ability to help breastfeeding dyads clinically. I had had 5 half-days a week during my junior year of upper-division anatomy and physiology. We had to learn how to teach a profoundly deaf child to lip read and then position their oral anatomy to produce intelligible sounds so they could “listen, talk, read, and succeed” (CID, 2023). I learned to focus on anatomy, the correct and incorrect functions. This applied to figuring out how to fit a mother’s breast and a baby’s mouth together to function properly for breastfeeding. I was able to approach helping dyads at these sessions in a clinical (hands-on) fashion. I learned so much from helping those mothers and babies. I could not always solve their problems, but I was sadly aware that there was no one more knowledgeable that could help them.

Most of our friends and my parents’ friends were physicians. My husband was an Obstetrics and Gyneacology (OB/GYN) resident when our first was born, and in practice when our second was born. I knew that not one of them had any knowledge, education, or experience with breastfeeding. Because of contact with local LLL Leaders, I knew their role was to provide basic breastfeeding education and mother-to-mother support. They were not trained or expected to function clinically. Personally, when local LLL Leaders had no idea how to solve my bleeding nipple problems, I was referred to a LLL Founder, who dealt with the medically related problems. The Founder suggested I walk around the block daily during our first phone conversation and during the second call that I wean my second baby from the problem breast/nipple, which sadly I did. I continued breastfeeding him on one breast until he self-weaned 2 years later. The Founder never mentioned that I could relactate. I suspect that in 1970, she didn’t know that was possible. I knew of no one to whom I could refer the breastfeeding problems I encountered.

Can you give us an example of how your personal experiences with breastfeeding improved your skill in helping others?

When my first baby was about 5 and a half months old, I returned to half-day teaching at CID. I tried many times to hand express my milk, on my own and from written descriptions of the skill available at that time, to leave milk for my baby during work hours. I only managed to cause skin burns, bruising, and pain. With my second and third baby, I knew skill with hand expression would allow me to rest my sore, bleeding nipple.

Shortly after child three was born in 1973, I “finally” figured out a pain-free, effective manual expression technique and how to cup-feed the expressed milk to him. I was unwilling to waste that precious milk I had expressed or resort to bottle feeding, which I strongly suspected would cause issues. I used a flexible soup bowl to catch my milk and cup-feed it back to him. Because he didn’t always need milk from both breasts, I eventually had over 100 8 oz. baby bottles full of milk in my freezer. About 2 years after he weaned (at 3 years and 4 months), the administrative head of LLL of Southern California (CA) phoned to ask me if the University of California, Los Angeles (UCLA) Hospital could have a few bottles of my milk. They had a 4-month-old baby who was dying—unable to digest every available formula. Someone finally suggested they try breastmilk. That baby kept my milk down without a problem. I donated all of the rest of my 2 to 5-year-old milk to keep that baby alive while they searched for more donor milk.

Soon after that, I started teaching hand expression to others—both at LLL meetings and to professionals a couple of years later, when invited to lecture. As this technique became more widely used, it became known as the “Marmet Technique.” When people requested the technique in writing, I struggled to “translate” a manual skill into written words, but when I finally accomplished this, others could easily read and convert it into an effective and safe manual skill (Marmet, 1978, reprinted often and in major textbooks); subsequently, it was included in many books and translated into many languages. Eventually, through a combination of my personal experiences, both working while breastfeeding and my painful bleeding nipple battles, many benefitted.

JD: How did your move to Los Angeles (LA), CA, influence your breastfeeding work?

In 1970, the move to LA gave me a much larger population base and a city with great creative energy. Mothers with breastfeeding concerns continued to find me. I provided frequent phone help and saw dyads with complex breastfeeding problems, including prematurity, relactation, induced lactation, and newborn deaths. Many of these complex situations required using equipment then available, for example, feeding tube devices and electric breast pumps (Marmet & Shell, 1988a).

My clinical breastfeeding workload, which started in late 1968 when my first was 3 months old, continued to grow exponentially after I became a LLL Leader in March 1975. Mothers needing breastfeeding help found me through referrals from physicians, hospital personnel, LLL Leaders and mothers’ word of mouth. I was inundated. In addition, I received many invitations to lecture in hospitals to nurses and physicians throughout Southern CA. I also lectured to many other groups, for example, LLL Leaders all over Southern CA, midwives, other health professionals and, annually, Dr. Derrick Jelliffe’s UCLA School of Public Health masters and doctoral students (1975–1992).

In what other ways did your practice expand?

In late 1975, under the La Leche League International (LLLI) banner, I opened a breast pump depot for the first quality electric breast pump company in the United States. I had four pumps for greater LA. When I rented a breast pump to a mother, each personal pump kit had written instructions, in seven languages, about how to attach all the pieces and plug the pump in, but zero instructions about how to best use the pump physiologically. The second mother who rented a pump from me, phoned a week later, and said, “This pump you rented me is making my preemie sick.” One of the NICU nurses had told her the pump was why her baby was sick. The mother then said, “I could sue you; I could sue LLL of Southern CA, and I could sue LLLI—and I just might.” I did my best to calm her and said I would get back to her as soon as possible. Then I phoned the U.S. head of the breast pump company and asked him to overnight a brand new, untouched-by-human-hands pump to me, which he did. I then spoke to Edwina Froechlich, one of LLLI’s seven Founding Mothers. I asked her if LLLI had insurance for its Leaders, and she said she would check into it. LLLI, of course, had no insurance for Leaders. I arranged for a local pathologist to examine the problematic pump, which I had exchanged for the brand-new electric breast pump. Though he found some milk backed up into tubing inside the pump (the result of incorrect usage), the tests he ran on the pump (inside and out) were negative for contamination concerns. There was clearly no cause for the concerns raised about the pump. The reactions were because it was a new piece of equipment, and the baby was not thriving. I also arranged for a local pediatrician, who had privileges at the hospital the baby was in, to check the baby’s records to determine if the breast pump could have caused a problem with the baby’s health. He confirmed there was nothing. The baby improved on his own, and the threatened lawsuit blew over; however, what came from this early incident was that I suggested the following to Edwina. If LLL Leaders were going to work with sick/hospitalized babies and/or mothers and equipment, LLLI needed insurance to protect Leaders from lawsuits, and needed to create a training program for Leaders so they were prepared to provide educated, special circumstance care.

Edwina said to me in response, “I’ll work on the insurance. You write the training program.” That was one of the defining moments for me on the path to creating the lactation consultant profession. From then on, I started keeping detailed records of every phone call and consultation and began researching how and when each specific piece of equipment (e.g., pumps, feeding tube devices) was needed and best used. For example, [regarding] pump usage, I started by suggesting each mother try two methods, which I determined and then explained, and get back to me about which worked better to physiologically establish/increase/decrease/maintain her milk supply, depending on that mother’s needs. I also did this research and record keeping with positional variations and sucking issues (Marmet & Shell, 1984, 1990a).

Another development that stemmed from this whole incident was that I suggested to the U.S. head of the breast pump company that they might consider including instructions in each personal pump kit explaining how the pump should be used physiologically. After I verbally shared some of my research findings with him, I was invited to write those instructions, which I did. My instruction about the physiologic use of breast pumps was included in every personal pump kit sold by several major breast pump companies in multiple languages (e.g., English, German, and Spanish) for over 20 years (starting in 1978). These instructions also were included in books and pamphlets, which hospitals copied (mostly without permission) until they became ubiquitous.

Initially, you tried to work through LLLI to professionalize lactation care. What happened?

In July of 1977, after 1.5 years of clinical research and data collection, the summation of my records of all the breastfeeding dyads I had worked with was hand-delivered to Edwina Froehlich at LLLI. The cover letter suggested that LLLI create a Lactation Consultant department and provide formal education to interested, experienced LLL Leaders to train them to work with what I then called special circumstance breastfeeding. I waited anxiously to hear back from LLLI but received no response. Over the next few months, I realized what I had proposed was beyond the scope of LLLI’s mission: To provide mother-to-mother support and basic breastfeeding information.

I was now in the unique position of having developed a new body of knowledge gained from my 9 years of experience working through problems with special circumstance breastfeeding dyads and formal clinical research (Marmet & Shell, 1988a). Each month, I grew increasingly overwhelmed with far more than full-time work, all pro bono. I could not care for all the mothers who needed breastfeeding help beyond what LLL Leaders were trained or expected to provide. Also, I realized that by functioning alone, I was scratching the surface of all I wanted to learn to enable me to provide better help to breastfeeding dyads. For this growth to occur, I needed peers.

During the early fall of 1977, like the previous year, I spent a 12-hour day at Cedars Sinai Medical Center, a large LA teaching hospital. I provided in-services for all nurses and most physicians, who worked in maternity services and NICU [neonatal intensive care unit], introducing them to basic clinical breastfeeding skills (Figure 1). Although, in both years, my lectures at Cedars were highly praised and evaluated, I observed that no change had been affected by receiving the previous year’s in-service. I felt exceedingly frustrated since I realized that my second “annual” in-service at this hospital was unlikely to produce better results. That night, as I walked to my car, I had my “lightbulb moment.” I knew, with absolute certainty, that we needed a new professional, the Lactation Consultant, who would be thoroughly trained, preferably with a university master’s degree in lactation consulting. It needed to be a technique-oriented, education-oriented, allied health profession. I knew that to effect change, hospital staff must learn to trust and appreciate this new allied medical professional. I knew they would also be hired to work in clinics, research, and private practice and would be needed worldwide.

Now the giant question was, how does one go from an epiphany to creating a living, breathing, new allied health field? Later that evening, I said to my husband, “I’m going to create a new profession, lactation consulting.” His now infamous response was, “Who would pay for breastfeeding care?” To Ellen Shell, my co-LLL Leader (since April 1975), I said, “I have a brilliant idea, and you have to do it with me!” She says, “Little did I realize that it was going to take the rest of my life.”

This was an enormous undertaking. What steps did you take first and why?

Ellen and I put our heads together for the next 2 years. We both agreed that to operate a graduate-level educational program, we each had to have a graduate degree. Our first thought was to earn degrees in registered nursing, which we were more than willing to do. We researched every nursing school program within driving distance of our homes. We learned, among other things, that while some educational requirements of these programs aligned, a large percentage diverged from what I knew by experience we needed to learn. It was only then that we investigated other fields of study.

We realized that the closest related professions to the one I envisioned were speech and language pathology, occupational therapy, and physical therapy (in that order). Other medical and allied medical professions (e.g., nursing and dietetics), along with many other degreed professions (e.g., public health, normal and abnormal child development, psychology, anatomy and physiology, pathology, toxicology, and education), also had aspects of what the LC would need to know (Marmet & Shell, 1988b). Mother-to-mother support counseling also provided a vital body of knowledge. Therefore, the educational program we planned to develop had to encompass aspects of all of these, as well as the art and science of breastfeeding, counseling breastfeeding dyads, and more (Marmet & Shell, 1988a).

For the previous 4 years, I had presented lectures to Dr. Derrick Jelliffe’s graduate classes in the School of Public Health at UCLA. Dr. Jelliffe worked closely with the World Health Organization (WHO) and was widely recognized as one of the world’s foremost experts in infant nutrition. He was also head of the Maternal/Child Division of Public Health at UCLA. He had created lactation support programs worldwide, detailed in his seminal book, Human Milk in the Modern World (Jelliffe & Jelliffe 1978). His work has influenced generations of breastfeeding advocates and program planners. Ellen and I hoped he would be an ally and guide us.

In the summer of 1978, we scheduled a meeting with Dr. Jelliffe, for which we created a one-page outline of the profession I was envisioning, and detailed why and what was needed. It was brief but thorough. Ellen and I shared it with Dr. Jelliffe and asked about being admitted to his Master of Public Health program at UCLA. His response, in his very proper English accent, was, “You must do this. There is nothing like this, and the world needs it. You must do this now! You are welcome in my MPH program now or any time in the future, but you must start the LC profession now!” When Dr. Jelliffe mentioned that his MPH program was only full-time, I said, “I can’t do that with a husband, three young kids, plus other current commitments.” He replied, “You definitely need a master’s degree to do what you have proposed, but it doesn’t matter what you get your master’s degree in, or where, as long as it is from a fully accredited institution. You must, however, start this profession now. Then, figure out how to get your master’s. The world needs lactation consultants now.” His enthusiasm inspired us to move forward with as much speed as our family responsibilities allowed.

Please talk us through the process you followed, step-by-step.

After our meeting with Dr. Jelliffe, the ideas Ellen and I had coalesced into our first task, the formation of a nonprofit, educational, allied health organization to serve as the role model for this new profession. Then, we tackled two significant projects. First, we needed to incorporate it as a nonprofit organization. We spoke to attorneys, seeking help with this endeavor, but could not afford their services. We asked them about the possibility of us writing our incorporation paperwork. Every attorney we spoke to said it could not be done. So, we bought a book on incorporating and proved them wrong.

How did your planning process evolve?

Our strategizing during the planning phase was so thorough that we never had to vary the basics of the way we operated. In making decisions, we always asked ourselves what was best for babies and mothers rather than what was good for us, the LI, or even the LC profession. We asked ourselves this question as we developed ideas for how to grow the profession, and every time a new issue arose. In retrospect, I think this was one of the most critical determinants of our success.

When did you start accepting students?

We started with one student in the early fall of 1979 who had been waiting in the wings. I had previously worked clinically with her so that after two unsuccessful breastfeeding attempts, she could fully breastfeed her third baby despite his being premature, very sick, and in the NICU for 3 months. When I shared my vision and plans with her, she was excited to be the LI’s first student. We did not have a formal training program during those first 3 months. However, I educated her, as I had Ellen, one-on-one, during that time, and she continued with us for several years, as a student and eventually as clinical faculty, until her family moved to the East Coast and then back to Europe several years later. She has been credited with taking the profession to Europe.

Please explain how your educational program continued to develop.

In January 1980, we started our formal educational program, which required one full didactic day a week for 12 months. Classes were held at Ellen’s house because it was the most centrally located for our students. The clinical education requirements included observing, sharing, and doing consults solo. This education took longer than the year’s didactic work because, to function safely, each student had to have gained sufficient supervised LC expertise with a wide variety of specified problems (Marmet & Shell, 1988b, 1990b). This included common and uncommon problems, which meant waiting for those with specific problems to schedule consults. Initially, we scheduled consults in both of our homes, depending on the location easiest for the breastfeeding dyad, and then notified all our students. Those who could come did. Then, we started scheduling most consults at Ellen’s house. First, we used one bedroom daily for consults. Over the next few months, we grew and required all of Ellen’s house 5 days a week. By the Summer of 1982, her husband said he wanted his house back; we temporarily rented a small house while we searched for office space with a landlord willing to build it to our specifications.

The Lactation Institute logo is very compelling. How was it created?

Ellen wanted our logo to be a tree like the one in a framed picture she loved (and still has). I wanted our logo to depict breast anatomy. So, we took Ellen’s picture and my anatomical idea to LLL Leader and artist Rosie Weisel, and she went to work. I visited Rosie’s home multiple times during the next couple of months. After each of Rosie’s renditions, I would take it home and work on and modify her drawing. Then I’d take it back to Rosie, and she would create the next version, each time polishing my drawings and making my suggestions part of an artistic rendition. We wanted an artistically depicted image that would stand the test of time incorporating accurate anatomy and Ellen’s tree. Rosie wanted to please us and create a professional-looking logo (Figure 3). Many years later, after Peter Hartmann, PhD, and his team published their ultrasound research on breast anatomy (Ramsay et al., 2005) I met some of them at a conference. They shared that our logo was the only anatomically correct depiction of the breast they had seen in cross-section drawings. Our logo has stood the test of time!

When did you and Ellen pursue your graduate degrees?

Shortly after the LI was operational, Ellen and I returned to fulfilling our goal of attaining our master’s degrees. After researching many master’s degree programs, we decided to apply. We were accepted at Pacific Oaks College (PO) in Pasadena, CA, which was available as a part-time program. They offered a degree in human development with two specializations: College teaching and educational administration. We felt a double major would benefit the work we were doing. We added a third specialization after starting our studies: Infant and toddler development. All three programs of study were perfect for our educational and practical needs. This decision was fortuitous because key PO faculty members got to know us and, in a few short years, welcomed establishing bachelor’s and master’s degree programs (in human development with a specialization in lactation consulting) in conjunction with the LI. Starting March 1985, our academic partnership operated and granted degrees for over 22 years. This affiliation proved a tremendous help in spreading and developing the professionalization of lactation consultancy.

You and Ellen accomplished so much in a relatively short time. When did you realize that this work was being appreciated nationally?

In January of 1980, we realized that word had spread nationally when Jan Riordan, a nurse and LLL Leader from Kansas, traveled to Los Angeles to visit the LI. She was gathering material for her first book, A Practical Guide to Breastfeeding (Riordan, 1983), aimed at teaching nurses about breastfeeding. Her research included personal visits with the tiny handful of MDs, RNs, and researchers working in some way professionally with breastfeeding. However, we were the only ones officially functioning as LCs. Among the many issues we discussed was how we each had dreamed of a professional association because contact between people functioning professionally is so important. We decided to put our lists together of all those already, or interested in, functioning professionally in lactation care or research. At Jan’s insistence, since the LI was already computerized, Ellen and I wrote a letter to everyone on the combined list (about 35–40 people) to see if there was any interest in starting a professional lactation association. We received a very minimal response; I realized the timing was too early. However, having a professional association remained one of my goals. So, I continued adding to this list every time the LI was contacted by someone interested in the LI educational program or was functioning professionally in lactation. This file was later used as the core of the first mailing list for creating a professional association for LCs (later named the International Lactation Consultants Association; ILCA). Jan shared details she had learned about the LI and LC profession with LLLI and many others she interviewed for her book. As she traveled, our work and my vision spread. Jan’s book contained the first nationally published information about the LI and the LC profession.

Chele, thank you. We have covered a lot of the early years of your work. This seems like a good place to stop the first part of our interview. The second part will continue chronologically with your journey, as the LC profession begins to take shape internationally. It will be published in the next issue of JHL.