I will be very interested to see the results of Hale's research. I think the causes are specific to patient population. That said, as a Hospital IBCLC, who has the ability to see the patient's as they follow up at the Outpatient Lactation Clinic we have, I think a big  cultural issue is not frequent enough nursing, and not being set up with some sort of Colostrum removal in the first 24 hours when Latch/etc is not going well. I tell my Mom's if you look at Sub Saharan Africa or Guatemala, where Breast Feeding is still the Norm, in the first 2 weeks when Milk is being established, these Babes nurse, several times an hour. To which they look at me with Abject horror. What? Do I have to feed that often? I tell them not  necesarily a few times an hour, but milk supply does depend on frequent and on demand feeding in the beginning and the reward is a rich/abundant milk supply on the other side. 
I had a couple today with a 4 LB  14 Oz 37 weeker Induced for IUGR.  Very weak suckle, I saw her at 36 hours out with a 8 % weight loss, going home right after I saw them, and right after circ URGH!  The RN had not set her up with a pump, I placed the Baby skin to skin and this helped wake him a little , but still not strong or active  enough suckle to transfer enough milk, no swallows appreciated.  I had her pump,  with properly fitted flanges, she obtained 10 ML total , which we were all happy about, but keep in mind that the Baby had been removing very little and this was after 36 hours of filling. If I had not seen her and  she had gone home, did not pump or supplement, I am sure the Baby would have been readmitted for the usual, and I am sure she would have become engorged, and then diminished milk supply if she had not had a way to remove her milk from her Breasts, until the baby becomes able to effectively empty her. So there are so many factors, this Mom was feeding on demand, but the Baby was not effective at milk transfer. Most often  though I go into the room and the parents are watching TV or visiting with family, and the Baby is either  asleep in the Crib  or has a pacifier in it's mouth, and has not been fed  in 4 to 5 hours.   So I think we should not demonize pumps, they do serve a purpose,  most of my patient's, Active duty military go back to work in 6 weeks, and have no choice but to pump. Although I do agree Manual expression/RPS, before you place an electric pump, does greatly increase milk yield. Most of my patient's make just too much for WIC but barely enough to survive in Expensive San Diego CA, so I do educate them about closed systems, i.e. Hygiea and Ameda, because they do pass them around for second time use to friends and family. 
Just my Two cents, Lisa Mooney MSN IBCLC CNM   		 	   		  
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