CourtListener 10680090

Testo completo

316 Ga. 383
FINAL COPY

S23A0017, S23X0018. RAFFENSPERGER v. JACKSON et al.; and
vice versa.

BOGGS, Chief Justice.

In 2018, Mary Jackson and a nonprofit organization, Reaching

Our Sisters Everywhere, Inc. (“ROSE”), filed a complaint against the

Secretary of State (“the Secretary”),1 challenging the

constitutionality of the Georgia Lactation Consultant Practice Act

(“the Act”), OCGA §§ 43-22A-1 to 43-22A-13. Under the Act, the

Secretary issues licenses authorizing lactation care providers to

provide lactation care and services for compensation. Only lactation

care providers who obtain a privately issued certification as an

International Board Certified Lactation Consultant (“IBCLC”) are

1 At the time the suit was filed, Brian Kemp was Secretary of State, and

he agreed to stay enforcement of the Act during the pendency of the suit. After
Kemp was elected Governor, the parties agreed to substitute current Secretary
of State Brad Raffensperger as the defendant, and Secretary Raffensperger
also agreed to stay enforcement of the Act until the conclusion of the case,
including any appeals.
eligible to obtain a license. Jackson and ROSE (collectively

“Plaintiffs”) allege that their work includes the provision of lactation

care and services and that the Act is irrational and lacks any real

and substantial connection to the public health, safety, or welfare

because there is no evidence that non-IBCLC providers of lactation

care and services have ever harmed the public. They also contended

that the Act will require them to cease practicing their chosen

profession, thus violating their rights to due process and equal

protection under the Georgia Constitution. See Ga. Const. of 1983,

Art. I, Sec. I, Pars. I and II. In the first round of this litigation, the

trial court granted the Secretary’s motion to dismiss for failure to

state a claim, but this Court reversed and remanded with direction.

See Jackson v. Raffensperger, 308 Ga. 736 (843 SE2d 576) (2020)

(“Jackson I”).

Following remand, the Secretary withdrew his motion to

dismiss, and the parties engaged in discovery and filed cross-

motions for summary judgment. On the due process claim, the trial

court granted the Secretary’s motion for summary judgment, and on

2
the equal protection claim, the trial court granted Plaintiffs’ motion

for summary judgment. The Secretary appealed, and Plaintiffs filed

a cross-appeal. For the reasons detailed below, we conclude in the

cross-appeal that the Act is unconstitutional on due process grounds

and that the trial court therefore erred in granting summary

judgment to the Secretary and denying it to Plaintiffs. Accordingly,

we reverse the trial court on the due process claim and do not reach

the equal protection claim raised in the main appeal.2

1. The background facts are undisputed. Lactation care

providers provide direct support to mothers in breastfeeding their

babies. While lactation care providers can make a living providing

their services, some volunteers also provide such support. Lactation

care providers may obtain certification from various private

accrediting entities, including the International Board of Lactation

Consultant Examiners, which began granting the IBCLC

2 The Court thanks Drs. Kleiner, Plemmons, and Timmons, Occupational

Licensing Scholars; Healthy Children Project, Inc.; Mom2Mom Global;
National Lactation Consultant Alliance, Inc. and Georgia Perinatal
Association; Pacific Legal Foundation and The Goldwater Institute; and
Southeastern Lactation Consultants Association for their briefs amicus curiae.
3
certification in 1985, and the Healthy Children Project, Inc., which

began granting certification as a Certified Lactation Counselor

(“CLC”) in 1992. IBCLC certification may be obtained in three

different pathways, each of which requires that a person pass a

written examination and complete 14 courses in health sciences,

eight of which must be college-level courses;3 95 hours of lactation-

specific education, including five focused on communication skills;

and at least 300 supervised clinical hours. The IBCLC examination

costs approximately $600-$700. The IBCLC program is accredited

by the National Commission for Certifying Agencies. There are

approximately 470 IBCLCs in Georgia, only 162 of whom have

obtained licenses under the Act.

To earn CLC accreditation, one must complete a 52-hour

3 According to the affidavit of the Secretary’s expert, the eight required

college-level courses are biology; human anatomy; human physiology; infant
and child growth and development; introduction to clinical research; nutrition;
psychology, counseling skills, or communication skills; and sociology, cultural
sensitivity, or cultural anthropology. The other six courses, which may be
completed as continuing education courses, are basic life support; medical
documentation; medical terminology; occupational safety and security for
health professionals; professional ethics for health professionals; and universal
safety precautions and infection control.

4
course; demonstrate competency in breastfeeding assessments,

counseling, teaching, infant weight gain, contraindications, and the

CLC Code of Ethics; and pass a written examination, which costs

approximately $120.4 The CLC course is accredited by the National

College Credit Recommendation Service, and its examination is

accredited by the American National Standards Institute. There are

currently approximately 735 CLCs in Georgia.

Lactation care providers can also receive education from

organizations such as ROSE. ROSE, which was founded in 2011,

trains individuals to provide breastfeeding education and support to

mothers, primarily in African-American communities, through a

4 According to the affidavit of Plaintiffs’ expert:

The CLC course covers breastfeeding management and the
underlying knowledge of anatomy and physiology that supports
the clinical skills needed for breastfeeding management. Topics
include, but are not limited to, theoretical foundations of milk
composition and milk production; health outcomes associated with
infant feeding choices; hand expression; milk storage and
handling; milk banking; contraindications to feeding human milk;
counseling; maternity care practices that influence breastfeeding
outcomes; assessing the breastfeed; breast problems; working
[while breastfeeding]; family planning; special challenges; effect of
foods and drugs; ages and stages of child development and infant
feeding; ethics; disparity in outcomes; and the Baby-Friendly
Hospital Initiative.
5
research and evidence-based curriculum in a free 16-hour course.

Approximately 1,000 individuals have participated in ROSE’s

training course.

In 2013, the General Assembly first considered a bill that

would require lactation care providers to be licensed through the

Secretary. See House Bill 363 (2013). Pursuant to OCGA § 43-1A-5

(a) (1), the Georgia Occupational Regulation Review Council

(“Review Council”) reviewed the proposal and unanimously

recommended against passage, and the 2013 bill did not become

law.5

In 2016, the General Assembly passed the Act, which is

substantially similar to the 2013 bill. The Review Council did not

review the Act prior to its passage. The General Assembly included

the following statement of purpose in the Act:

The General Assembly acknowledges that the
application of specific knowledge and skills relating to
breastfeeding is important to the health of mothers and
babies and acknowledges further that the rendering of
sound lactation care and services in hospitals, physician

5 The law establishing the Review Council, see OCGA § 43-1A-1 et seq.,

has been repealed. See Ga. L. 2023, p. ___, § 1.
6
practices, private homes, and other settings requires
trained and competent professionals. It is declared,
therefore, to be the purpose of this chapter to protect the
health, safety, and welfare of the public by providing for
the licensure and regulation of the activities of persons
engaged in lactation care and services.

OCGA § 43-22A-2. The Act defines “lactation care and services” as

“the clinical application of scientific principles and a

multidisciplinary body of evidence for evaluation, problem

identification, treatment, education, and consultation to

childbearing families regarding lactation care and services,” OCGA

§ 43-22A-3 (5), and provides a nonexhaustive list of lactation care

and services. Under the Act, “[l]actation care and services shall

include, but not be limited to:”6

(A) Lactation assessment through the systematic
collection of subjective and objective data;
(B) Analysis of data and creation of a lactation care
plan;
(C) Implementation of a lactation care plan with
demonstration and instruction to parents and

6 By specifying that the named services “shall include, but not be limited

to,” the list is not exhaustive. Compare Premier Health Care Investments, LLC
v. UHS of Anchor, L.P., 310 Ga. 32, 45 (849 SE2d 441) (2020) (concluding that
General Assembly’s use of “including but not limited to” in a statute introduced
a list of illustrative examples rather than an exhaustive list).
7
communication to the primary health care provider;
(D) Evaluation of outcomes;
(E) Provision of lactation education to parents and
health care providers; and
(F) The recommendation and use of assistive
devices.
Id. Under OCGA §§ 43-22A-3 (6), 43-22A-6, and 43-22A-7, the

Secretary may grant a license as a “lactation consultant” only to a

person who has obtained an IBCLC certification or who holds a

license issued by another jurisdiction if the requirements for that

license are equal to or greater than the requirements of the Act. And

under OCGA § 43-22A-11, “no person without a license as a lactation

consultant issued pursuant to this chapter shall . . . practice

lactation care and services,” unless one of the exemptions set forth

in OCGA § 43-22A-13 applies.7 Anyone who provides lactation care

and services for compensation without a license may be subjected to

injunction proceedings in superior court. See OCGA § 43-1-20.8

7 See n.12, below.
8 The general provisions of Title 43, which governs professions and
businesses, authorize professional licensing boards to enter cease-and-desist
orders against the unlicensed practice of a profession without a license and to
impose a fine of up to $500 for the violation of a cease-and-desist order. See

8
Jackson is a CLC and is employed by a hospital, where her job

duties include providing services that fall within the Act’s definition

of “lactation care and services,” including counseling mothers about

breastfeeding, assessing breastfeeding challenges, creating and

implementing lactation care plans, evaluating breastfeeding

outcomes, assisting mothers with babies in the neonatal intensive

care unit with breastfeeding help, and helping mothers use various

tools, such as breast pumps. After the Act was passed, she was

informed by her supervisor that she would not be permitted to

continue doing the same job duties.

ROSE employs CLCs and also trains individuals to provide

lactation care services directly to mothers, including breastfeeding

assessment, education, and support. ROSE offers lactation care and

services to mothers without cost, and while some of the individuals

trained by ROSE work as volunteers, others are paid for their work

by ROSE.

OCGA § 43-1-20.1 (b). The Act authorizes the Secretary to impose sanctions on
licensed lactation consultants. See OCGA §§ 43-22A-10; 43-22A-12.
9
2. In considering Plaintiffs’ challenges to the Act, we begin with

the standard of review. Our review of the trial court’s order is de

novo because this appeal is from a ruling on cross-motions for

summary judgment and raises a legal question as to the

constitutionality of a law. See Polo Golf and Country Club

Homeowners Assn. v. Cunard, 310 Ga. 804, 809 (854 SE2d 732)

(2021) (“Our review of the grant or denial of a motion for summary

judgment is de novo.” (cleaned up)); State v. Holland, 308 Ga. 412,

414 (841 SE2d 723) (2020) (“[W]e review de novo the trial court’s

conclusion regarding the constitutionality of [a statute]”).

But the issues presented are not wholly legal, as the parties

presented evidence for the trial court’s consideration on the motions

for summary judgment. Therefore, in considering the propriety of

the trial court’s ruling on either motion, we view the evidence in the

light most favorable to the nonmovants. Because we conclude that

the trial court erred not only in granting summary judgment for the

Secretary on the due process claim, but in denying it to Jackson and

ROSE, we apply the same standard to Plaintiffs’ motion, and view

10
the evidence in the light most favorable to the Secretary. See

Chandler v. Robinson, 269 Ga. 881, 884 (506 SE2d 121) (1998)

(concluding on review of cross-motions for summary judgment “that

the undisputed facts, even when viewed in a light most favorable to

[the losing party], evidence an absence of genuine issue as to any

material fact[,] and [therefore the prevailing party was] entitled to

summary judgment as a matter of law”), disapproved of on other

grounds by Shearin v. Wayne Davis & Co., 281 Ga. 385 (637 SE2d

679) (2006).

Case No. S23X0018

3. We now turn to the issues presented in the cross-appeal.

Plaintiffs contend that the trial court erred in granting the

Secretary’s motion for summary judgment on their due process

claim. They assert that the Act violates their due process rights

because it precludes them from practicing their lawful, chosen

profession as providers of lactation care and services. The Secretary,

for his part, contends that the Act does not preclude Plaintiffs from

pursuing their profession and that, regardless, the General

11
Assembly’s choice to license only IBCLCs to provide lactation care

and services is rationally related to the Act’s stated purpose of

“protect[ing] the health, safety, and welfare of the public,” OCGA

§ 43-22A-2, and by promoting access to quality care.

The Georgia Constitution’s Due Process Clause provides that

“[n]o person shall be deprived of life, liberty, or property except by

due process of law.” Ga. Const. of 1983, Art. I, Sec. I, Par. I.9

We have “long recognized” that this provision “entitles Georgians to

pursue a lawful occupation of their choosing free from unreasonable

government interference.” Jackson I, 308 Ga. at 740. We discerned

this right not merely from precedent, but also as a “consistent and

definitive” understanding of Georgia’s Due Process Clause. See

Elliott v. State, 305 Ga. 179, 184 (824 SE2d 265) (2019) (“A

constitutional clause that is readopted into a new constitution and

that has received a consistent and definitive construction is

9 The language of the Due Process Clause has remained materially the

same for these purposes since it first appeared in the Georgia Constitution of
1861. See State v. Turnquest, 305 Ga. 758, 769 (827 SE2d 865) (2019) (tracing
language of Due Process Clause through Constitutions of 1861, 1865, 1868,
1877, 1945, 1976, and 1983).
12
presumed to carry the same meaning as that consistent

construction.”). Across each successive Constitution following the

addition of the Due Process Clause in 1861, we articulated a

consistent and definitive understanding of how the Due Process

Clause applied to occupational licensing and the ability to pursue a

lawful occupation. This understanding begins as far back as 1896,

Odell v. City of Atlanta, 97 Ga. 670 (25 SE 173) (1896), past the turn

of the century, Bazemore v. State, 121 Ga. 619, 620 (49 SE 701)

(1905), through the 1930s, Southeastern Elec. Co. v. City of Atlanta,

179 Ga. 514 (176 SE 400) (1932) and Bramley v. State, 187 Ga. 826,

832 (2 SE2d 647) (1939), the 1950s and 1960s, Jenkins v. Manry, 216

Ga. 538, 541-546 (118 SE2d 91) (1961), all the way up to the middle

of the committee meetings to revise Article 1 of the Constitution,

Rockdale County v. Mitchell’s Used Auto Parts, Inc., 243 Ga. 465,

465 (254 SE2d 846) (1979); Transcripts of Mtgs., Committee to

Revise Article I, Vol. 1 (Meetings 1977-1981). Our cases, in sum,

display a consistent and definitive understanding of the

Constitution’s Due Process Clause, reaffirmed at least once under

13
the 1945 Constitution’s Due Process Clause, and referenced

approvingly under the short-lived 1976 Constitution.10 Thus, “[the]

history reveal[s] a consistent and definitive construction” of the Due

Process Clause, “whose words remain[ ] materially unchanged since

[they] first appeared” in their present form, and (since we have been

offered no evidence to the contrary) “we presume[ ] that construction

10 We have also decided a number of strikingly similar cases in this
stretch that either did not directly tie themselves to the Due Process Clause,
or cited the Equal Protection Clause instead. See, e.g., Cooper v. Rollins, 152
Ga. 588, 590-591 (110 SE 726) (1922) (a law requiring barbers, not other
professionals in “trades involving manual labor,” to get a license, was not
irrational and therefore did not violate equal protection; the state had the
“police power” to require a license for barbers, and “[t]he health of the citizens
as affected by diseases spread from barber shops conducted by unclean and
incompetent barbers is justification for such laws,” so the legislature could do
that “without requiring the members of all other trades or occupations to be so
examined and licensed”); Gregory v. Quarles, 172 Ga. 45, 47-48 (157 SE 306)
(1931) (a law requiring plumbers to obtain a license before working on new
plumbing, but not existing plumbing, violated equal protection: “there is
respectable authority for saying that[,] since a city may easily protect itself
against the consequences of bad plumbing, by a system of inspecting the work
itself, rather than by limiting the number of persons who shall engage in it,
those statutes and ordinances which provide that none but examined and
licensed persons shall engage in plumbing skirt pretty closely that border line
beyond which legislation ceases to be within the powers conferred by the people
of the State upon its legislative bodies.” (cleaned up)).
That is significant because, at the time, our cases also suggested that the
related equal protection attack on occupational licensing was “so intimately
connected” with the due process inquiry as to “not require separate
consideration.” Bramley, 187 Ga. at 832; see also Southeastern Elec., 179 Ga.
at 514 (concluding that the same examination requirement for electrical
contractors violated both due process and equal protection).
14
was carried forward into the 1983 Constitution.” Elliott, 305 Ga. at

184.

The contours of the right we reaffirmed in Jackson I, as shown

by this consistent and definitive understanding, are as follows. It is

“the common inherent right of every citizen to engage in any honest

employment he may choose, subject only to such restrictions as are

necessary for the public good.” Bramley, 187 Ga. at 834-835. “The

[constitutional] regulation of a lawful business . . . is dependent upon

some reasonable necessity for the protection of the [1] public health,

[2] safety, [3] morality, or [4] other phase of the general welfare; and

unless an act restricting the ordinary occupations of life can be said

to bear some reasonable relation to one or more of these general

objects of the police power, it is repugnant to constitutional

guaranties and void.” Id. at 835. So, for example, “an unjust

discrimination between classes of persons” will often violate the

disfavored class’s rights, particularly if “the actions of one class in

following the vocation . . . would affect the [government’s interests]

as materially as the actions of the other class.” Jenkins, 216 Ga. at

15
541-546.

To be clear, this does not mean the right is concerned with

invidious discrimination along the lines of modern equal protection

analysis. Instead, it is concerned with the imposition of arbitrary

(i.e., not reasonably necessary) burdens on the ability to pursue a

lawful occupation. Disparate treatment is not the violation itself; it

is evidence of the violation — if a similarly situated person is able to

pursue the occupation competently, then the burden imposed on the

person who is prohibited from pursuing the occupation is likely not

reasonably necessary to the State’s interest in health and safety. See

Jenkins, 216 Ga. at 545-546 (“There is no reasonable basis for

requiring the examination and licensing of plumbers and steam

fitters who are not employees of public-utility corporations, and

exempting employees of public-utility corporations operating in the

territory covered by the act.”); Southeastern Elec., 179 Ga. at 514 (an

ordinance regulating electrical contractors and requiring them to

pass examinations depending on whether they performed their work

in new buildings versus existing buildings was so arbitrary and so

16
standardless that it violated due process and equal protection).

Although we have previously considered a number of

constitutional challenges to occupational licensing schemes, we have

not identified a specific framework to apply in considering such

challenges under the Georgia Constitution. And our early case law

addressing such challenges often failed to carefully distinguish the

constitutional claims asserted. See, e.g., Bramley, 187 Ga. at 832

(state and federal due process and equal protection challenges to

statute requiring licensure of photographers presented

“substantially a single question”). Nevertheless, this case law, which

we discuss further below, and case law addressing due process

challenges to statutes in other contexts, provides helpful guidance

and allows us to establish a framework for considering the challenge

here.

First, in order to establish that the Act violates their due

process rights under the Georgia Constitution to pursue their chosen

occupation free from unreasonable government interference,

challengers bear the burden of establishing that the Act “manifestly

17
infringes upon a constitutional provision or violates the rights of the

people.” Brodie v. Champion, 281 Ga. 105, 106 (636 SE2d 511)

(2006); see also Zarate-Martinez v. Echemendia, 299 Ga. 301, 305

(788 SE2d 405) (2016) (burden is on the party challenging the

constitutionality of statute). In the context of a challenge to an

occupational licensing scheme, this first step requires the challenger

to establish two things.

The challenger must show that the occupation sought is, at a

minimum, lawful but for the challenged restriction. Jackson I, 308

Ga. at 740 (collecting cases describing the right as pursuing a lawful

occupation free from unreasonable government interference); see

also Odell, 97 Ga. at 671 (“[T]he keeping of an establishment for the

purpose of enabling persons to bet upon horse-races is not a useful

or necessary occupation which any citizen has either a common law

or constitutional right to carry on.”); Schlesinger v. City of Atlanta,

161 Ga. 148, 159 (129 SE 861) (1925) (the right to pursue a lawful

occupation “has no application to the inhibition of that which the

individual has no natural or inherent right to do. If the individual

18
has no such inherent right to conduct the business of a common

carrier by jitneys or busses upon the streets of the city, his case does

not fall within this principle.”).

And the challenger must also show that the regulation

“unreasonabl[y] . . . interfere[s]” with the ability “to pursue a lawful

occupation of their choosing free from unreasonable government

interference[.]” Jackson I, 308 Ga. at 740; see also Bramley, 187 Ga.

at 832 (the defendant in a criminal prosecution for violating

occupational licensing restrictions on photographers successfully

argued that “the statute on which the accusation was based [was]

unconstitutional and void” because it was “an arbitrary and

unreasonable interference with a lawful and harmless business”).

These two showings — that an occupation is otherwise lawful

and that a regulation unreasonably burdens the ability to pursue it

— are the indispensable elements of a claim that a given law violates

the right to pursue a lawful occupation free from unreasonable

government interference.

In the second step in the framework, the government must

19
offer a legitimate interest behind the regulation justifying some

interference with the ability to pursue the occupation. This is not an

open-ended exercise in interest-balancing — our consistent and

definitive understanding of the Due Process Clause shows well-

settled limits on what government interests are sufficient for these

purposes: a burden on the ability to practice a lawful occupation is

only constitutional if it is reasonably necessary to advance an

interest in health, safety, or public morals. See Bramley, 187 Ga. at

835-836 (listing government interests as “public health, safety,

morality, or other phase of the general welfare”); Jenkins, 216 Ga.

at 540 (“The right to work and make a living . . . may be abridged to

the extent, and only to the extent, that is necessary reasonably to

insure the public peace, safety, health, and like words of the police

power.” (emphasis added) (quoting Richardson v. Coker, 188 Ga.

170, 175 (3 SE2d 636) (1939)). And while this same understanding

does not require the challenger to disprove “any reasonably

conceivable state of facts that could provide a rational basis for the

classification,” as the rational basis test does under federal law, see

20
Fed. Communications Comm. v. Beach Communications, Inc., 508

U.S. 307, 313 (113 SCt 2096, 124 LE2d 211) (1993), neither does it

call on courts to analyze whether a justification offered in litigation

is the “real” one. See, e.g., Cooper v. Rollins, 152 Ga. 588, 593-594

(110 SE 726) (1922); Bramley, 187 Ga. at 838-839; Jenkins, 216 Ga.

at 540. There is no requirement that the government must compile

or offer evidence in the course of enacting such a regulation, nor that

the government defend such an act solely by reference to some

purported legislative intent.

Conversely, this same consistent and definitive understanding

makes clear that certain interests are decidedly not sufficient to

justify a burden on the ability to practice a lawful profession. These

include (1) protectionism and (2) generic interests of quality or

honesty of goods and services, especially when this latter sort of

interest is unmoored from the particular profession — i.e., when the

given profession does not create special need to deal with the quality

or honesty of goods and services, but shares those risks on the same

terms as some other business not so regulated. See, e.g., Bramley,

21
187 Ga. at 836-837 (speaking of licensing photographers: “No

business, however innocent and harmless, is entirely free from the

possibility of becoming, under improper or dishonest management,

in some degree inimical to the public interest . . . . If this should be

held to be a sound argument, the police power could be used to lay

upon any business, however unrelated to the general welfare, [and

however] burdensome and unreasonable [the] restrictions.” (cleaned

up)); see also Moultrie Milk Shed v. City of Cairo, 206 Ga. 348, 352

(57 SE2d 199) (1950) (“[O]ne engaged in a lawful business injurious

to no one must not be arbitrarily prevented from the legitimate

prosecution of his business by city ordinances which set up trade

barriers solely for the purpose of protecting a resident against

proper competition.”). In short, once the challenger has made a

prima facie case, the government must offer (but not necessarily

prove the veracity or efficacy of) a specific interest in health, safety,

or public morals. If the government fails to offer such an interest, or

offers only an illegitimate interest, the regulation violates the right

to pursue an occupation free from unreasonable government

22
interference. See Bramley, 187 Ga. at 834, 838.11

Third, and finally, the challenger has the ultimate burden to

prove that the regulation unreasonably interferes with her right to

practice the occupation of her choosing. Because statutes are

presumed to be constitutional, this burden starts and remains with

the challenger throughout. See, e.g., Cooper, 152 Ga. at 591 (“What

such regulation shall be, and to what particular trade or business

such regulation shall apply, are questions for the State to determine,

and their determination comes within the proper exercise of the

police power of the State”; there must be “clear and palpable” conflict

before “an act of the legislature will be declared unconstitutional”);

Bramley, 187 Ga. at 832 (referencing the “duty of sustaining [an] act

11 None of our prior cases resolving state due process challenges to
occupational licensing statutes expressly adopted the federal due process test,
which generally gives extraordinary deference to the legislature in
determining whether a stated interest is legitimate. Therefore, our prior cases
applying that test to state due process challenges in other contexts are not
controlling here. See, e.g., Women’s Surgical Ctr., LLC v. Berry, 302 Ga. 349,
354-355 (806 SE2d 606) (2017) (applying federal due process test to state
constitutional due process challenge to statute requiring certificate of need for
new healthcare facility); Quiller v. Bowman, 262 Ga. 769, 770-771 (425 SE2d
641) (1993) (applying federal due process test to state constitutional due
process challenge to state statute requiring suspension of driver’s license upon
conviction for possession of controlled substance or marijuana).
23
unless its invalidity is clear and palpable”); see also Richardson, 188

Ga. at 175 (“[R]easonableness as such is not a primary matter of

inquiry . . . . [T]he violation of the constitution may arise from

unreasonableness if it extends to the point of arbitrariness or

consists in unlawful discriminations.”).

Indeed, not every burden on the ability to pursue a lawful

occupation will be unconstitutional — sometimes a regulation will

be “rational” in the sense that it is reasonably necessary (either

actually or because of the failure of the challenger to meet her

burden). See, e.g., Cooper, 152 Ga. at 593-594 (rejecting a challenge

to an occupational regulation of barbers to prevent “[t]he spread of

disease by unsanitary . . . barber shops”). But if the challenger can

establish that a regulation imposing restrictions on a lawful

occupation does not advance the articulated public purpose by

means that are reasonably necessary for that purpose, then the

regulation cannot stand. See Bramley, 187 Ga. at 834 (“The

regulation of a lawful business . . . is dependent upon some

reasonable necessity for the protection of the public health, safety,

24
morality, or other phase of the general welfare . . . .”); Cooper, 152

Ga. at 591 (regulation of trades is general within the police power of

the legislature unless the ability to pursue an occupation is

“unnecessarily and in the main arbitrarily interfered with”).

4. With this framework in mind, we begin with the first step,

which requires answering two questions: (a) whether Plaintiffs have

established that they are engaged in a lawful profession as lactation

care providers; and (b) whether the Act actually burdens them in

their practicing of a lawful profession.

(a) The Secretary makes no argument that the profession of

lactation consultant is not a legal occupation, and indeed the

General Assembly has specifically “acknowledge[d] that the

application of specific knowledge and skills relating to breastfeeding

is important to the health of mothers and babies.” OCGA § 43-22A-

2. We thus conclude that Plaintiffs have met their burden of showing

that there is no genuine issue of material fact as to that issue.

(b) We next address Plaintiffs’ contention that the Act imposes

burdens on practicing their chosen profession as lactation care

25
providers. As noted above, only lactation care providers who hold an

IBCLC license are permitted to practice “lactation care and

services,” under the Act,12 and “[l]actation care and services” are

defined as “the clinical application of scientific principles and a

multidisciplinary body of evidence for evaluation, problem

identification, treatment, education, and consultation to

childbearing families regarding lactation care and services.” OCGA

§ 43-22A-3 (5). Additionally, the Act sets forth a nonexhaustive list

of activities that constitute lactation care and services. See OCGA §

43-22A-3 (5) (A)-(F).13

12 OCGA § 43-22A-11 provides that a person who falls within one of the

exemptions set forth in OCGA § 43-22A-13 is not prohibited from practicing
lactation care and services. Those exemptions cover individuals licensed to
practice other healthcare professions, such as dentistry and medicine, when
incidental to the practice of their profession; doulas and perinatal and
childbirth educators, when performing education functions consistent with the
standards of their professions; students under the supervision of an IBCLC or
other licensed healthcare professional; certain state and federal government
employees when in the discharge of their official duties; volunteers;
nonresident IBCLCs; and other healthcare professionals seeking licensure for
their professions. It is undisputed that Plaintiffs do not fall within one of the
exemptions.
13 Because “lactation care and services” is defined, circularly, as the

provision of “lactation care and services,” the enumeration of specific activities
is helpful to an understanding of the contours of the Act.
26
In considering whether the language of the Act covers

Plaintiffs’ professional activities, we begin with the statutory text

and read it “in its most natural and reasonable way, as an ordinary

speaker of the English language would.” Zaldivar v. Prickett, 297

Ga. 589, 591 (774 SE2d 688) (2015) (cleaned up). Here, although

“clinical” is not defined in the Act, it has a common and well-

understood meaning as “of, relating to, or conducted in or as if in a

clinic: such as (a) involving direct observation of the patient [or] (b)

based on or characterized by observable and diagnosable

symptoms.” Merriam-Webster Dictionary (7th paperback ed.

2016).14 And this definition is consistent with the definition

applicable in the healthcare setting as well. See Dorland’s

Illustrated Medical Dictionary (28th ed. 1994) (defining “clinical” as

“pertaining to a clinic or to the bedside; pertaining to or founded on

actual observation and treatment of patients, as distinguished from

14 When looking for the commonly understood meaning of a word in
statutory text, we generally look to dictionaries and, if relevant, legal
dictionaries from the time the statute was passed. See State v. Henry, 312 Ga.
632, 637 (864 SE2d 415) (2021).
27
theoretical or basic sciences”). Thus, “clinical application” in the

context of the provision of lactation care means services that are

provided directly by a care provider to breastfeeding mothers.

The trial court did not determine whether the Act burdens

Plaintiffs in the practice of their profession, but it did conclude that

“not all lactation care providers are providing care that rises to the

statutory definition of ‘lactation care and services,’”15 based on its

conclusion that the phrase “clinical application” excludes

breastfeeding education from the scope of “lactation care and

services.” Similarly, the Secretary argues that Plaintiffs may

continue their work as “lactation peers and counselors” because such

work is not a clinical service.16

However, the record indisputably shows that the vast majority

15 This conclusion appears to be inconsistent with the trial court’s
determination in ruling on the equal protection claim that “all non-IBCLC
providers are similarly situated to IBCLC providers because they perform the
same type of work.”
16 The Secretary’s argument contradicts, without explanation, the official

opinion of Georgia’s Attorney General that a person who is certified as a CLC
and who does not fall within one of the Act’s exemptions is prohibited from
performing the type of services covered under the Act. See Op. Atty. Gen. 2018-
1 (Jan. 24, 2018).
28
of the work Plaintiffs are paid to do in working as lactation care

providers involves direct observation of, and interaction with,

mothers and their nursing babies and includes one or more of the

activities specifically enumerated as “lactation care and services.”

Moreover, the trial court’s determination and the Secretary’s

argument ignore the plain meaning of “clinical” as working directly

with patients as well as the inclusion of “lactation education to

parents” within the Act’s definition of lactation care and services.

See OCGA § 43-22A-3 (5) (E). Furthermore, the undisputed evidence

establishes that the scope of the services that CLCs are trained to

perform includes comprehensive assessment of mothers and their

babies related to breastfeeding; the development of an evidence-

based care plan specific to the needs identified in the assessment;

implementation of that care plan; and an evaluation of the

effectiveness of breastfeeding and milk transfer. Each of these

services falls within the statutory definition of lactation care and

services enumerated in OCGA § 43-22A-3 (5) (A)-(F).

And while the record indicates that the scope of practice of

29
individuals trained by ROSE is not as comprehensive as the scope of

practice of a CLC or an IBCLC, the record does establish that

lactation care providers trained by ROSE work directly with

mothers to provide education about breastfeeding and how to be

successful in breastfeeding their babies.

Finally, while the evidence shows that there are significant

differences in the training required to receive certification as an

IBCLC or CLC or to be trained as a lactation care provider by ROSE,

these differences are not dispositive. The real question is whether

Plaintiffs’ professional activities meet the Act’s definition of

“lactation care and services” as including the application of

“scientific principles and a multidisciplinary body of evidence for

evaluation, problem identification, treatment, education, and

consultation . . . regarding lactation care and services.” OCGA § 43-

22A-3 (5). And Plaintiffs’ professional activities do meet that

definition. Indeed, the evidence shows that the training provided by

the Healthy Children Project (for certification as a CLC) and by

ROSE includes, at a minimum, education in “scientific principles

30
and a multidisciplinary body of evidence” to equip them to provide

lactation education directly to mothers. Accordingly, we conclude

that (even in the light most favorable to the Secretary) Plaintiffs

have met their burden of showing that the Act in fact imposes

significant burdens on them in providing lactation care and services

for remuneration.

5. We must next consider whether the State has a sufficient

interest in restricting the provision of lactation care and services for

compensation only to individuals who have attained certification as

an IBCLC.

(a) The Act’s stated purpose is “to protect the health, safety,

and welfare of the public,” OCGA § 43-22A-2, which is, at least on

its face, a well-recognized basis for legislative enactments dealing

with the ability to pursue a lawful occupation.17 See, e.g., Bramley,

187 Ga. at 834-835 (recognizing that there “are many occupations

17 As noted above, another well-recognized basis for occupational
licensing schemes exists where occupations “afford peculiar opportunity for
imposition and fraud.” Bazemore, 121 Ga. at 619. The Secretary makes no
argument that the occupation of lactation care provider is one that offers a
peculiar opportunity for fraud.
31
which may be regulated for the promotion of the public welfare”).

But Georgia’s Due Process Clause requires more than a talismanic

recitation of an important public interest. Moreover, as discussed

above, our cases make clear that a challenger need not negate every

conceivable basis for an occupational licensing scheme. Therefore,

we focus our analysis on the Secretary’s proffered rationale for the

Act — promoting access to quality care.18

As Bramley makes clear, a generic interest in promoting access

to quality services — at least in the absence of a unique tie to the

provision of lactation care and services — is not a sufficient interest

for these purposes. In Bramley, this Court considered a

constitutional challenge to a statute requiring that photographers

obtain a license to engage in commercial photography and

photofinishing. To obtain the license, a photographer was required

to pass a written examination given by a newly formed State Board

of Photographic Examiners and to “qualify as to competency, ability,

18 The Secretary’s focus on “quality” care is consistent with the Act’s

statement that the “rendering of sound lactation care and services . . . requires
trained and competent professionals.” OCGA § 43-22A-2.
32
and integrity.” Id. at 833. Bramley, whose work involved soliciting

orders for the enlargement and tinting of photographs by his

employer, was prosecuted for violating the statute because neither

he nor his employer was licensed under the statute. Id. at 833-834.

Bramley challenged the constitutionality of the statute, and we

concluded that there was no “basis affecting the public interest for

the requirement of examination ‘as to competency, ability, and

integrity.’” Id. at 834. We expressly rejected the notion that the

statute might be upheld under the theory that an unskilled

photographer producing inferior quality prints might cause some

injury to the public or that a dishonest photographer might commit

fraud. Id. at 838; see also Richardson, 188 Ga. at 174-175 (the police

power did not allow the government to subject an electrician “to the

judgment of a board . . . for the purpose of determining whether he

may be reasonably expected to satisfactorily complete any contracts

he enters into” (cleaned up)).

In contrast, where this Court has upheld regulatory laws

intended to further public health, safety, and welfare, the regulation

33
has been reasonably necessary to advance a specific health, safety,

or welfare concern. For example in City of Lilburn v. Sanchez, 268

Ga. 520, 522-524 (491 SE2d 353) (1997), we upheld a municipal

ordinance forbidding the keeping of a pot-bellied pig as a pet on a lot

of less than one acre where direct and expert evidence showed

distinct harm to the health and welfare of neighbors and the public

from keeping a pet pig on smaller lots. See also Bazemore, 121 Ga.

at 620-621 (“When stolen from the field of the owner, [seed-cotton]

is almost impossible to be identified. It is therefore especially

difficult to make laws relating to larceny or receiving stolen goods

effective in preventing the crime [of stealing it] by punishing the

thief,” making a law requiring the written consent of the owner of

land a valid exercise of the police power.).

In summary, the question is (at a minimum) whether the

particular trade is peculiarly “infected with some quality that might

render it dangerous to the morals, the health, the comfort, or the

welfare of . . . the public.” Bramley, 187 Ga. at 836. Thus, it may well

be true that regulations promoting quality care are desirable as a

34
policy matter, but that is not a sufficient interest to justify an

unreasonable burden on the ability to pursue a lawful occupation.

(b) Applying the above principles to the evidence presented

below, we conclude that the Secretary’s proffered interest in the

restrictions imposed by the Act — promoting access to quality care

— is an insufficient basis upon which to authorize only IBCLCs to

provide lactation care and services for compensation given our

consistent and definitive understanding of the scope of the due

process right to practice one’s chosen profession free from

unreasonable government restrictions. The Secretary does not

contend that the Act is inherently a health and safety regulation —

that, say, unlicensed lactation consultants would do affirmative

harm to (in the way a surgeon might), as opposed to merely failing

to help, their patients. Certainly, there is nothing inherently

harmful in the practice of lactation care, and there is no evidence of

harm to the public from the provision of lactation care and services

by individuals who lack an IBCLC license. Compare Richardson,

188 Ga. at 174 (acknowledging obvious risk of fire from defectively

35
installed electrical wiring and so authorizing regulation of

installation of electrical wiring for safety of public).

Moreover, the record supports the trial court’s conclusion that

CLCs and the individuals educated by ROSE are trained to provide

safe and competent lactation care and services within their

respective scopes of practice. The Secretary admitted that he is not

aware of any evidence of harm from a person providing lactation

care and services either prior to or after the passage of the Act and

that the advisory group set up under the Act, see OCGA § 43-22A-4,

has not received any complaints regarding untrained or incompetent

providers of lactation care and services. And careful review of the

affidavits and depositions of experts and lactation care providers

entered into the record fails to reveal any injury to mothers or babies

caused by lactation care providers of any type. Finally, we note that

the record contains the Review Council’s report of the 2013 version

of the Act. That report concludes that there is evidence that having

access to proper lactation support has many benefits; that in its

review, which included hearings, there was “no substantive evidence

36
of harm identified” that flowed from the unregulated provision of

lactation care; and that prohibiting CLCs from providing lactation

care may cause “a greater risk of harm because the majority of

lactation consultant providers would no longer be able to provide

care.”

In the absence of evidence of harm, the Secretary relies on

speculation to suggest that there is a danger to breastfeeding

mothers and nursing babies from “unqualified and untrained”

lactation care providers. At oral argument, the Secretary contended

that a lactation care provider without the IBCLC certification might

lead to the premature cessation of breastfeeding, which would result

in the baby and mother not receiving the benefits of breastfeeding19

or to the continuance of breastfeeding that is inadequate for a baby’s

nutritional needs. Such speculation, in the face of substantial

19 The rationale that regulation of a legal occupation is needed because

incompetent practitioners could lead to a reduction in the public having access
to the occupation could be used to justify any licensing regime. See Bramley,
187 Ga. at 838 (reasoning that if licensing requirement for photographers were
determined to be valid “it would seem that there is scarcely any kind of
business, however innocent and harmless, to which similar regulations might
not be applied”).
37
evidence that the provision of lactation care and services by non-

IBCLC providers is safe for and beneficial to nursing mothers and

babies, is insufficient to authorize the regulatory scheme adopted,

which greatly restricts those able to be employed as lactation care

providers.20

For the foregoing reasons, we conclude that the Act violates

Plaintiffs’ due process rights under the Georgia Constitution to

practice the chosen profession of lactation care provider.

Accordingly, we reverse the trial court’s rulings on the due process

claim. Because we have determined that the Act is unconstitutional

20 We note that while statutes in other states provide for the licensing of

lactation care providers, no other state has enacted a statutory scheme that
categorically prohibits a CLC from providing lactation care services for
compensation, contrary to the Secretary’s assertion. See Or. Rev. Stat. §
676.681 (2) (c) (Lactation Consultant Act does not prohibit any “person whose
training and national certification attest to the person’s preparation and
ability to practice their profession or occupation from practicing the profession
or occupation in which the person is certified, if the person does not represent
that the person is a lactation consultant”); N.M. Stat. Ann. § 61-3B-1 et seq.
(establishing licensing of lactation care providers, including for persons
certified “by a certification program accredited by any nationally or
internationally recognized accrediting agency” if approved by state’s board of
nursing, and providing that Lactation Care Provider Act shall not prevent
practice of lactation care and services by unlicensed persons so long as they do
not represent themselves as licensed providers).
38
on one of the grounds asserted, we need not address Plaintiffs’

arguments that the trial court erred in ruling that the Act does not

violate their equal protection rights under the Georgia Constitution.

Accordingly, we vacate the trial court’s ruling in Case No. S23A0017.

Judgment reversed in Case No. S23X0018. Judgment vacated
in Case No. S23A0017. All the Justices concur, except Pinson, J.,
disqualified.

39
Decided May 31, 2023.

OCGA § 43-22A-1 et seq.; constitutional question. Fulton

Superior Court. Before Judge Dunaway.

Christopher M. Carr, Attorney General, Margaret K. Eckrote,

Deputy Attorney General, Maximillian J. Changus, Senior Assistant

Attorney General, Melissa A. Tracy, Assistant Attorney General,

Stephen J. Petrany, Solicitor-General, Ross W. Bergethon, Deputy

Solicitor-General, for Raffensperger.

Heidari Power Law Group, Yasha Heidari; Renee D. Flaherty,

Jaimie Cavanaugh, for Jackson et al.

Smith Gambrell & Russell, Anthony L. Cochran, Emma H.

Cramer; Rouse & Copeland, Amy L. Copeland; Husch Blackwell, A.

James Spung, Joseph S. Diedrich, Rebecca C. Furdek; Ashby Thelen

Lowry, Maxwell K. Thelen; Eugene R. Curry; Glenn A. Delk, Timothy

M. Sandefur, Wilson C. Freeman; King & Spalding, Madison H.

Kitchens, J. Franklin Sacha, Jr., Seth I. Euster, amici curiae.

NOTICE: This opinion is subject to modification resulting from motions for reconsideration under Supreme Court
Rule 27, the Court’s reconsideration, and editorial revisions by the Reporter of Decisions. The version of the
opinion published in the Advance Sheets for the Georgia Reports, designated as the “Final Copy,” will replace any
prior version on the Court’s website and docket. A bound volume of the Georgia Reports will contain the final and
official text of the opinion.

In the Supreme Court of Georgia

Decided: May 31, 2023

S23A0017. RAFFENSPERGER v. JACKSON et al.
S23X0018. JACKSON et al. v. RAFFENSPERGER.

BOGGS, Chief Justice.

In 2018, Mary Jackson and a nonprofit organization, Reaching

Our Sisters Everywhere, Inc. (“ROSE”), filed a complaint against the

Secretary of State (“the Secretary”),1 challenging the

constitutionality of the Georgia Lactation Consultant Practice Act

(“the Act”), OCGA §§ 43-22A-1 to 43-22A-13. Under the Act, the

Secretary issues licenses authorizing lactation care providers to

provide lactation care and services for compensation. Only lactation

care providers who obtain a privately issued certification as an

At the time the suit was filed, Brian Kemp was Secretary of State, and
1

he agreed to stay enforcement of the Act during the pendency of the suit. After
Kemp was elected Governor, the parties agreed to substitute current Secretary
of State Brad Raffensperger as the defendant, and Secretary Raffensperger
also agreed to stay enforcement of the Act until the conclusion of the case,
including any appeals.
International Board Certified Lactation Consultant (“IBCLC”) are

eligible to obtain a license. Jackson and ROSE (collectively

“Plaintiffs”) allege that their work includes the provision of lactation

care and services and that the Act is irrational and lacks any real

and substantial connection to the public health, safety, or welfare

because there is no evidence that non-IBCLC providers of lactation

care and services have ever harmed the public. They also contended

that the Act will require them to cease practicing their chosen

profession, thus violating their rights to due process and equal

protection under the Georgia Constitution. See Ga. Const. 1983, Art.

I, Sec. I, Pars. I and II. In the first round of this litigation, the trial

court granted the Secretary’s motion to dismiss for failure to state a

claim, but this Court reversed and remanded with direction. See

Jackson v. Raffensperger, 308 Ga. 736 (843 SE2d 576) (2020)

(“Jackson I”).

Following remand, the Secretary withdrew his motion to

dismiss, and the parties engaged in discovery and filed cross-

motions for summary judgment. On the due process claim, the trial

2
court granted the Secretary’s motion for summary judgment, and on

the equal protection claim, the trial court granted Plaintiffs’ motion

for summary judgment. The Secretary appealed, and Plaintiffs filed

a cross-appeal. For the reasons detailed below, we conclude in the

cross-appeal that the Act is unconstitutional on due process grounds

and that the trial court therefore erred in granting summary

judgment to the Secretary and denying it to Plaintiffs. Accordingly,

we reverse the trial court on the due process claim and do not reach

the equal protection claim raised in the main appeal. 2

1. The background facts are undisputed. Lactation care

providers provide direct support to mothers in breastfeeding their

babies. While lactation care providers can make a living providing

their services, some volunteers also provide such support. Lactation

care providers may obtain certification from various private

accrediting entities, including the International Board of Lactation

2 The Court thanks Drs. Kleiner, Plemmons, and Timmons, Occupational
Licensing Scholars; Healthy Children Project, Inc.; Mom2Mom Global;
National Lactation Consultant Alliance, Inc. and Georgia Perinatal
Association; Pacific Legal Foundation and The Goldwater Institute; and
Southeastern Lactation Consultants Association for their briefs amicus curiae.
3
Consultant Examiners, which began granting the IBCLC

certification in 1985, and the Healthy Children Project, Inc., which

began granting certification as a Certified Lactation Counselor

(“CLC”) in 1992. IBCLC certification may be obtained in three

different pathways, each of which requires that a person pass a

written examination and complete 14 courses in health sciences,

eight of which must be college-level courses; 3 95 hours of lactation-

specific education, including five focused on communication skills;

and at least 300 supervised clinical hours. The IBCLC examination

costs approximately $600-$700. The IBCLC program is accredited

by the National Commission for Certifying Agencies. There are

approximately 470 IBCLCs in Georgia, only 162 of whom have

obtained licenses under the Act.

3 According to the affidavit of the Secretary’s expert, the eight required
college-level courses are biology; human anatomy; human physiology; infant
and child growth and development; introduction to clinical research; nutrition,
psychology, counseling skills, or communication skills; and sociology, cultural
sensitivity, or cultural anthropology. The other six courses, which may be
completed as continuing education courses, are basic life support, medical
documentation, medical terminology, occupational safety and security for
health professionals, professional ethics for health professionals, and universal
safety precautions and infection control.

4
To earn CLC accreditation, one must complete a 52-hour

course; demonstrate competency in breastfeeding assessments,

counseling, teaching, infant weight gain, contraindications, and the

CLC Code of Ethics; and pass a written examination, which costs

approximately $120.4 The CLC course is accredited by the National

College Credit Recommendation Service, and its examination is

accredited by the American National Standards Institute. There are

currently approximately 735 CLCs in Georgia.

Lactation care providers can also receive education from

organizations such as ROSE. ROSE, which was founded in 2011,

trains individuals to provide breastfeeding education and support to

4 According to the affidavit of Plaintiffs’ expert,
The CLC course covers breastfeeding management and the
underlying knowledge of anatomy and physiology that supports
the clinical skills needed for breastfeeding management. Topics
include, but are not limited to, theoretical foundations of milk
composition and milk production; health outcomes associated with
infant feeding choices; hand expression; milk storage and
handling; milk banking; contraindications to feeding human milk;
counseling; maternity care practices that influence breastfeeding
outcomes; assessing the breastfeed; breast problems; working
[while breastfeeding]; family planning; special challenges; effect of
foods and drugs; ages and stages of child development and infant
feeding; ethics; disparity in outcomes; and the Baby-Friendly
Hospital Initiative.
5
mothers, primarily in African-American communities, through a

research and evidence-based curriculum in a free 16-hour course.

Approximately 1000 individuals have participated in ROSE’s

training course.

In 2013, the General Assembly first considered a bill that

would require lactation care providers to be licensed through the

Secretary. See House Bill 363 (2013). Pursuant to OCGA § 43-1A-5

(a) (1), the Georgia Occupational Regulation Review Council

(“Review Council”) reviewed the proposal and unanimously

recommended against passage, and the 2013 bill did not become

law. 5

In 2016, the General Assembly passed the Act, which is

substantially similar to the 2013 bill. The Review Council did not

review the Act prior to its passage. The General Assembly included

the following statement of purpose in the Act:

The General Assembly acknowledges that the application
of specific knowledge and skills relating to breastfeeding
is important to the health of mothers and babies and

The law establishing the Review Council, see OCGA § 43-1A-1 et seq.,
5

has been repealed. See 2023 Ga. Laws Act 57 (HB 76) (May 1, 2023).
6
acknowledges further that the rendering of sound
lactation care and services in hospitals, physician
practices, private homes, and other settings requires
trained and competent professionals. It is declared,
therefore, to be the purpose of this chapter to protect the
health, safety, and welfare of the public by providing for
the licensure and regulation of the activities of persons
engaged in lactation care and services.

OCGA § 43-22-2A. The Act defines “lactation care and services” as

“the clinical application of scientific principles and a

multidisciplinary body of evidence for evaluation, problem

identification, treatment, education, and consultation to

childbearing families regarding lactation care and services,” OCGA

§ 43-22A-3 (5), and provides a nonexhaustive list of lactation care

and services. Under the Act, “[l]actation care and services shall

include, but not be limited to:”6

(A) Lactation assessment through the systematic
collection of subjective and objective data;
(B) Analysis of data and creation of a lactation care plan;
(C) Implementation of a lactation care plan with
demonstration and instruction to parents and

6 By specifying that the named services “shall include, but not be limited
to,” the list is not exhaustive. Compare Premier Health Care Investments, LLC
v. UHS of Anchor, L.P., 310 Ga. 32, 45 (849 SE2d 441) (2020) (concluding that
General Assembly’s use of “including but not limited to” in a statute introduced
a list of illustrative examples rather than an exhaustive list).
7
communication to the primary health care provider;
(D) Evaluation of outcomes;
(E) Provision of lactation education to parents and
health care providers; and
(F) The recommendation and use of assistive devices.

Id. Under OCGA §§ 43-22A-3 (6), 43-22A-6, and 43-22A-7, the