Can't resist responding again to this thread after reading through the posts from the past few days.  Each one has made me think, hard.  I take the points you are making and I have real respect for the various perspectives you have.

First, I hope no one thinks that I would ignore a breastfeeding history like the one Michelle describes in which the mother had experienced breastfeeding failure with her three previous children and was now on the fourth.  I would have started talking to that woman about hypoplasia and a physiologic reason for her supply problems when they arose with her first child if I suspected that was the problem.  But I strongly doubt whether I would have commented on the appearance of her breasts and a possible risk for low supply if I met her on day one after the birth of that first child, and I would be even less likely to mention it in pregnancy.  Always, if the woman voices a concern I strive to deal with it honestly, fully and supportively.  But I am just as adamant about not burdening her with my concerns before they have shown any sign of turning into real problems.  Far be it from me to be the one to undermine her confidence.
  
Actually, my hesitance to mention the risk of low supply to a particular group of women is because nowadays I fear for every woman's chances of exclusively breastfeeding.  This comes from having worked for the last six or seven years seeing mainly women with serious breastfeeding problems of one kind or another.  When I was simply working on a general postpartum ward I assumed breastfeeding would work until proven otherwise, and I viewed problems as 'unusual', 'exceptions' to the rule, which was normal breastfeeding.  Now, our ward has been reorganized so all the women who have uncomplicated births stay in a hotel-like facility post partum where I never see them, and the only ones left in the hospital  ward are the ones with five strikes against them before they ever have the baby at their breast.   If a woman says breastfeeding is going well on day two or three I am now suspicious and incredulous.  I find myself wanting to watch her baby feed so I can find the problem she hasn't even noticed yet, and normal breastfeeding has become the exceptional circumstance in my mind.
 
This sad realization has helped me to understand why obstetricians are so suspicious of birth.  If the only thing you see is the scenario when nothing is working, you forget that the rest exists.  It makes me sad, and angry, to think my trust in womens' ability to feed their children has been so deeply shaken.  I still hold that *if you have the opportunity to provide close follow-up*, (and that's a big if, I know), there is little or nothing to be gained by starting to talk about hypoplasia at first glance.  The point is, we don't know, ever, how a woman's breasts will function or how breastfeeding will play out for her and her baby.  That's why postpartum follow-up exists at all; we need to have some way to find the at-risk babies before they suffer intoloerably, and we need to provide a safe framework in which breastfeeding can flourish, or not, without putting any babies in danger or sowing groundless doubts that do more harm than good.  Once again the analogy to birth comes to mind - we can not simply act as though problems never arise in labor nor can we treat every pregnant woman as if we assume she will require a cesarean to get her baby out.  We need to let birth and breastfeeding happen in safe environments that promote and protect the normal process while allowing timely and appropriate intervention when necessary.   

I hope no woman I have worked with has ever felt I've tried to disempower her by waiting until signs of trouble arise before bringing up the subject of an anatomic reason for her breastfeeding difficulties.  But as Heather pointed out, there are often lots of much more ordinary reasons for low supply.  In Maya's post, the mother had gotten such a flawed idea about what normal feeding looked like that I am tempted to say the hypoplasia may not have been relevant to her problems; any woman following the advice described in that post would likely end up with low supppy at best, and outright weaning in the first 2 weeks at worst.    

Rachel Myr
Kristiansand, Norway

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