Experience of the First Breastfeeding Session in Association with the Use of the Hands-On Approach by Healthcare Professionals: A Population-Based Swedish Study

Abstract

Objective:

The aim of this study was to investigate the prevalence of healthcare professionals' use of the hands-on approach during the first breastfeeding session postpartum and its possible association with the mothers' experience of their first breastfeeding session.

Materials and Methods:

This was a population-based longitudinal study conducted at Uppsala University Hospital, Uppsala, Sweden, of all women giving birth at the hospital from May 2006 to June 2007. Six months postpartum, a questionnaire including questions regarding breastfeeding support, caregiving routines, depressive symptoms, and the woman's experience of the first breastfeeding session was sent to the mothers. The main outcome measures were use of the hands-on approach during the first breastfeeding session and the mother's experience of the breastfeeding session.

Results:

In total, 879 women participated in the study. Thirty-eight percent of the women received the hands-on approach during the first breastfeeding session. High body mass index, primiparity, and having the first breastfeeding session postponed were all independently associated with the hands-on approach. Women who received the hands-on approach were more likely to report a negative experience of the first breastfeeding session (odds ratio=4.48; 95% confidence interval, 2.57–7.82), even after adjustment for possible confounders (odds ratio=2.37; 95% confidence interval, 1.02–5.50).

Conclusions:

This study indicates that the hands-on approach is commonly used during the first breastfeeding session and is associated with a more negative experience of the first breastfeeding session. Consequently, caregivers need to question the use of this method, and further research about breastfeeding support is required.

Introduction

Breastfeeding provides infants with nutrients for healthy growth and development¹ and is associated with a reduction in risk for sudden infant death syndrome, necrotizing enterocolitis, and neonatal infections.² Infants who are not breastfed exclusively during the first months are more likely to suffer from several health problems.³ Breastfeeding may also provide benefits for mothers, for example, by reducing the prevalence of hypertension, diabetes, hyperlipidemia, and cardiovascular disease,⁴ and breastfeeding may also protect mothers from breast cancer and ovarian cancer.^5,6 The World Health Organization recommends exclusive breastfeeding up to 6 months, with continued breastfeeding with additional food up to 2 years of age or beyond.¹

To promote successful breastfeeding, every facility providing maternity services and care for newborn infants should give mothers confidence in how to breastfeed and help them initiate breastfeeding within half an hour of birth.⁷ Previous research on clinical practice has come to the conclusion that the contact between the mother and her infant should be uninterrupted during the first hour after birth or until the first breastfeeding session has been accomplished to promote and stimulate the infant to take the breast him- or herself.⁸

Studies investigating mothers' experience of breastfeeding are important in assessing the optimal way for physicians, nurses, and midwives to guide women to successful breastfeeding. According to these studies, help with an optimal positioning is important in preventing breastfeeding problems. However, the hands-on approach—in which the healthcare professionals use their hands in touching the woman's breast and the baby in order to stimulate latch on and breastfeeding—is often described by new mothers as disrespectful, physically intrusive, distressing, and embarrassing.^9–13 A Swedish study of qualitative design shows that a hands-off technique—supporting the mother's own ability to breastfeed through encouragement, oral information, and demonstration on how to latch on—gave a more positive experience for the breastfeeding mothers.⁹ Despite the results of previous studies, some researchers have argued that there is little evidence of how well the hands-off breastfeeding support, which avoids handling the breasts or “forcing” the baby onto the breast, affects maternal satisfaction or breastfeeding outcomes.¹⁴

The aim of this study was to investigate the prevalence of the hands-on approach during the very first breastfeeding session postpartum and to investigate its correlates as well as its possible association with the mothers' experience of the first breastfeeding session.

Materials and Methods

This study was undertaken as a part of the UPPSAT (Uppsala-Athens Project on Postnatal Depression) Study, a population-based cohort in the county of Uppsala, Sweden, investigating correlates of postnatal depression in Sweden. The study was conducted at the Department of Obstetrics and Gynecology at Uppsala University Hospital, Uppsala, Sweden. Uppsala is a medium-sized Swedish county with a population of 323,270 inhabitants, and the University Hospital is responsible for all women giving birth within the county as well as high-risk pregnancies from referral counties.

The study protocol was approved by the Regional Research and Ethics Committee of Uppsala.

Study population

From May 2006, to June 2007, all eligible women giving birth at Uppsala University Hospital were contacted by their midwife or midwife's assistant after giving birth and asked about their willingness to participate. Detailed information on the study is provided in previous reports.^15–20 The current study uses data from two questionnaires, at 5 days and 6 months postpartum. Sociodemographic data were gathered from the first questionnaire, 5 days postpartum, and another questionnaire with additional questions was sent to the mothers 6 months postpartum.

Study variables and outcome measures

The second questionnaire included statements such as “At the first breastfeeding session the healthcare professionals helped me breastfed by using their hands to attach my breast with the baby's mouth” and “The first breastfeeding session was a positive experience to me,” with yes/no alternative answers. The mothers' subjective experience of the first breastfeeding session (positive or negative) was used as the outcome variable. Information on various perinatal correlates and experience of giving birth (rated as excellent, good, ok, bad, or awful) was also included. The variable was then dichotomized as a positive (excellent, good, or okay) or negative (bad or awful) experience of giving birth.

Statistical analyses

Univariate analyses were performed to assess the associations between sociodemographic or obstetric factors and the hands-on approach as well as a negative experience of the first breastfeeding session. Odds ratios and 95% confidence intervals were calculated using a variance of the Mantel–Haenszel procedure. Multivariate logistic regression was used to estimate the specific effect of the background variables on the hands-on approach. A second multivariate logistic regression model was applied, with negative breastfeeding experience as the outcome variable and the hands-on approach as well as a series of possible predictor variables. SPSS version 18.0 software (SPSS, Inc., Chicago, IL) was used for the statistical analyses. The level of statistical significance was set at a p value of 0.05.

Results

In total, 879 women (56% of all eligible women) answered the questionnaires. Of the participating women, 7% were under the age of 25 years, whereas 16% were older than 34 years of age. Sixty-one percent of the women had a higher education (college or university). Fifty percent were first-time mothers, and 99% of the women were married or cohabitant. Eighty-seven percent of the women were in gestational week 37–41 at the time of delivery, and 12 participants (1%) had a multiple gestation. Sixteen percent of the women were delivered by cesarean section.

Thirty-eight percent of the women experienced the hands-on approach during their first breastfeeding session, whereas 92% reported having a positive experience of the first breastfeeding session. Seventy-four percent of the women had their first breastfeeding session at the delivery ward, whereas the remaining reported postponed breastfeeding, which first occurred at the maternity ward, the neonatal intensive care unit, or elsewhere.

Table 1 gives the results from the univariate analyses, with possible associations between the hands-on approach and sociodemographic, medical history, and obstetric variables. The results indicate that an increased risk for the hands-on approach existed if the woman was a primipara, under the age of 25 years, had a low level of education, had been smoking during pregnancy, or had a body mass index (BMI) of >25 kg/m².

Table 1.

Sociodemographic Characteristics and Obstetric Variables in Association with the Hands-On Approach at First Breastfeeding Session

	Hands-on [n (%)]
Variable	No	Yes	OR	95% CI
Sociodemographic characteristics
Age (years)
<25	16 (38.1)	26 (61.9)	2.82	1.47–5.40
25–34	291 (63.4)	168 (36.6)	1.0	1
≥35	75 (78.1)	21 (21.9)	0.49	0.29–0.82
BMI (kg/m²)
≤25	302 (66.1)	155 (33.9)	1.0	1
>25	102 (54.5)	85 (45.5)	1.62	1.15–2.30
Family status
Married/cohabitant	442 (63.0)	260 (37.0)	1.0	1
Single	5 (62.5)	3 (37.5)	1.02	0.24–4.30
Education level
High	294 (67.4)	142 (32.6)	1.0	1
Low	153 (56.0)	120 (44.0)	1.62	1.19–2.22
Parity
Multipara	284 (80.9)	67 (19.1)	1.0	1
Primipara	162 (45.3)	196 (54.7)	5.13	3.66–7.20
Smoking during pregnancy
No	399 (63.5)	229 (36.5)	1.0	1
Yes	8 (40.0)	12 (60.0)	2.61	1.05–6.49
Stressful life event 6 weeks postpartum
No	339 (64.9)	183 (35.1)	1.0	1
Yes	96 (62.7)	57 (37.3)	1.10	0.76–1.60
Previous psychiatric contact
No	345 (63.5)	198 (36.5)	1.0	1
Yes	104 (61.2)	66 (38.8)	1.11	0.78–1.58
Obstetric variables
Cesarean section
No	452 (63.6)	259 (36.4)	1.0	1
Yes	75 (56.0)	59 (44.0)	1.37	0.95–2.00
Vaginal rupture
No	270 (63.2)	157 (36.8)	1.0	1
Yes	260 (60.9)	167 (39.1)	1.11	0.84–1.46
EDA during delivery
No	379 (65.6)	199 (34.4)	1.0	1
Yes	146 (55.5)	117 (44.5)	1.53	1.13–2.05
Medical nitrous oxide/oxygen mixture during delivery
No	154 (68.8)	70 (31.2)	1.0	1
Yes	371 (60.1)	246 (39.9)	1.46	1.05–2.02
Weight of the baby (g)
<2,500	12 (42.9)	16 (57.1)	2.30	1.07–4.93
2,501–4,499	478 (63.3)	277 (36.7)	1.0	1
>4,500	21 (63.6)	12 (36.4)	0.99	0.48–2.04
Place/setting during first breastfeeding
Delivery ward	427 (68.1)	200 (31.9)	1.0	1
Other^a	101 (45.1)	123 (54.9)	2.60	1.90–3.55
Experience of the first breastfeeding session
Positive	507 (65.4)	268 (34.6)	1.0	1
Negative	19 (29.7)	45 (70.3)	4.48	2.57–7.82
Experience of giving birth
Positive	310 (61.8)	192 (38.2)	1.0	1
Negative	194 (63.0)	114 (37.0)	0.95	0.71–1.27
Successful breastfeeding during hospital stay
Yes	401 (72.0)	156 (28.0)	1.0	1
No	82 (34.9)	153 (65.1)	4.80	3.46–6.64
Formula supplementation during hospital stay
No	415 (64.7)	226 (35.3)	1.0	1
Yes	71 (45.2)	86 (54.8)	2.22	1.56–3.17

Maternity ward, neonatal intensive care unit, or operating theater, which consequently indicates a postponed first breastfeeding session.

BMI, body mass index; CI, confidence interval; EDA, epidural local anesthetic; OR, odds ratio.

Women using medical nitrous oxide/oxygen mixture or epidural anesthesia during delivery and women who were breastfeeding for the first time in the maternity ward (postponed breastfeeding) also had a higher risk of being exposed to the hands-on approach, as had women giving birth to small infants (weighing less than 2,500 g). Women reporting breastfeeding problems during the hospital stay or reporting that formula supplementation was given to the newborn while in the hospital more often experienced the hands-on approach. Furthermore, women exposed to the hands-on approach were also at higher risk to report their first breastfeeding session as a negative experience.

The results describing associations between negative experience of the very first breastfeeding and a series of variables are shown in Table 2. Women reporting their first breastfeeding session as a negative experience were more likely to report postponed breastfeeding, breastfeeding problems, or need for formula supplementation for the baby during the hospital stay or had received the hands-on approach during the first breastfeeding session.

Table 2.

Sociodemographic Characteristics and Obstetric Variables in Association with a Negative Experience of the First Breastfeeding Session

	Experience of the first breastfeeding session [n (%)]
Variable	Positive	Negative	OR	95% CI
Sociodemographic characteristics
Age (years)
<25	39 (92.9)	3 (7.1)	0.78	0.23–2.64
25–34	416 (91.9)	41 (9.0)	1.0	1
≥35	94 (96.9)	3 (3.1)	0.32	0.10–1.07
BMI (kg/m²)
≤25	487 (93.8)	32 (6.2)	1.0	1
>25	166 (87.8)	23 (12.2)	2.11	1.2–3.71
Family status
Married/cohabitant	652 (92.5)	53 (7.5)	1.0	1
Single	5 (71.4)	2 (28.6)	4.9	0.96–26.0
Education level
High	407 (93.3)	29 (6.7)	1.0	1
Low	249 (90.5)	26 (9.5)	1.47	0.84–2.55
Parity
Multipara	338 (95.2)	17 (4.8)	1.0	1
Primipara	318 (89.3)	38 (10.7)	2.38	1.31–4.30
Smoking during pregnancy
No	582 (92.1)	50 (7.9)	1.0	1
Yes	17 (85.0)	3 (15.0)	2.05	0.58–7.25
Stressful life event 6 weeks postpartum
No	495 (93.8)	33 (6.2)	1.0	1
Yes	137 (91.3)	13 (8.7)	1.42	0.73–2.78
Previous psychiatric contact
No	508 (93.4)	36 (6.6)	1.0	1
Yes	152 (88.9)	19 (11.1)	1.76	0.98–3.17
Obstetric variables
Cesarean section
No	664 (93.4)	47 (6.6)	1.0	1
Yes	117 (87.3)	17 (12.7)	2.05	1.14–3.70
Vaginal rupture
No	402 (94.6)	23 (5.4)	1.0	1
Yes	387 (90.2)	42 (9.8)	1.90	1.12–3.21
EDA during delivery
No	532 (91.9)	47 (8.1)	1.0	1
Yes	245 (93.5)	17 (6.5)	0.79	0.44–1.40
Medical nitrous oxide/oxygen mixture during delivery
No	204 (91.1)	20 (8.9)	1.0	1
Yes	573 (92.9)	44 (7.1)	0.78	0.45–1.36
Weight of the baby (g)
<2,500	24 (85.7)	4 (14.3)	2.09	0.70–6.22
2,501–4,499	701 (92.6)	56 (7.4)	1.0	1
>4,500	29 (93.5)	2 (6.5)	0.86	0.20–3.71
Place/setting during first breastfeeding
Delivery ward	606 (95.6)	28 (4.4)	1.0	1
Other^a	181 (83.4)	36 (16.6)	4.31	2.56–7.25
Hands-on approach
No	507 (96.4)	19 (3.6)	1.0	1
Yes	268 (85.6)	45 (14.4)	4.48	2.57–7.82
Experience of giving birth
Positive	479 (94.5)	28 (5.5)	1.0	1
Negative	268 (89.0)	33 (11.0)	2.11	1.25–3.56
Successful breastfeeding during hospital stay
Yes	550 (97.3)	15 (2.7)	1.0	1
No	176 (78.2)	49 (21.8)	10.21	5.59–18.65
Formula supplementation during hospital stay
No	607 (94.8)	33 (5.2)	1.0	1
Yes	123 (80.4)	30 (19.6)	4.49	2.64–7.63

Maternity ward, neonatal intensive care unit, or operating theater, which consequently indicates a postponed first breastfeeding session.

BMI, body mass index; CI, confidence interval; EDA, epidural local anesthetic; OR, odds ratio.

Obstetric factors associated with a negative experience of the first breastfeeding session were a negative experience of giving birth, vaginal rupture, and cesarean section.

Primiparous women and women with a BMI of >25 kg/m² were more likely to report their first breastfeeding session as a negative experience. Women given the opportunity to accomplish the first breastfeeding session while in the delivery ward (breastfeeding not postponed) were less likely to report a negative experience of the first breastfeeding session.

In Table 3, the results from the multivariate logistic regression analysis are given, with the hands-on approach as the outcome variable and obstetric/life style variables as the predictor variables. Having a BMI of >25 kg/m², being a first-time mother, low level of education, and breastfeeding for the first time in a place other than the delivery ward (postponed breastfeeding) were all independently associated with an increased risk of receiving the hands-on approach at the very first breastfeeding session.

Table 3.

Multiple Logistic Regression-Derived Odds Ratios and 95% Confidence Intervals for the Hands-On Approach at First Breastfeeding Session in Relation to Associated Risk Factors

	OR (95% CI)
Variable	Model 1	Model 2
BMI (kg/m²)
≤25	1	1
>25	1.48 (1.00–2.17)	1.63 (1.04–2.56)
Parity
Multipara	1	1
Primipara	4.90 (3.42–7.01)	4.33 (2.80–6.70)
Place/setting during first breastfeeding session
Delivery ward	1	1
Other^a	2.65 (1.78–3.95)	3.14 (1.94–5.08)
Education level
High	1	1
Low	1.78 (1.25–2.54)	1.85 (1.20–2.90)
Use of medical nitrous oxide/oxygen mixture
No	1	1
Yes	1.33 (0.88–2.01)	1.82 (1.11–2.98)
EDA during delivery
No		1
Yes		1.06 (0.70–1.64)
Age (years)
<25		2.42 (0.81–7.22)
25–34		1
≥35		0.62 (0.26–1.45)
Smoking during pregnancy
No		1
Yes		0.64 (0.20–2.10)

Maternity ward, neonatal intensive care unit, or operating theater, which consequently indicates a postponed first breastfeeding session.

BMI, body mass index; CI, confidence interval; EDA, epidural local anesthetic; OR, odds ratio.

Table 4 gives the results from the multivariate logistic regression, with negative experience of the first breastfeeding session as the outcome variable and the hands-on approach as well as a series of possible predictor variables. Even after adjusting for confounders such as BMI, parity, postponed breastfeeding, experience of giving birth, previous psychiatric contact, the woman's age, and the presence of a stressful life event in the previous 6 months, the hands-on approach was associated with a negative first breastfeeding experience (odds ratio=2.37; 95% confidence=1.02–5.50).

Table 4.

Multiple Logistic Regression-Derived Odds Ratio and 95% Confidence Intervals for a Negative Experience of the First Breastfeeding Session in Relation to the Hands-On Approach at the First Breastfeeding Session

	OR (CI)
Variable	Model 1	Model 2	Model 3
Hands-on approach at first breastfeeding session
No	1	1	1
Yes	4.48 (2.57–7.82)	2.48 (1.22–5.04)	2.37 (1.02–5.50)
BMI (kg/m²)
≤25		1	1
>25		1.71 (0.90–3.24)	1.90 (0.87–4.17)
Parity
Multipara		1	1
Primipara		1.76 (0.85–3.66)	1.88 (0.78–4.54)
Place/setting during first breastfeeding session
Delivery ward		1	1
Other^a		2.93 (1.54–5.56)	3.16 (1.42–7.05)
Experience of giving birth
Good		1	1
Bad		2.28 (1.22–4.28)	2.45 (1.13–5.33)
Previous psychiatric contact
No		1	1
Yes		1.96 (1.01–3.80)	2.22 (0.99–4.94)
Age (years)
25–34			1
<25			0.99 (0.21–4.73)
≥35			0.51 (0.14–1.90)
SLE during the previous 6 months
≥1			1
≥2			2.00 (0.87–4.56)

Maternity ward, neonatal intensive care unit, or operating theater, which consequently indicates a postponed first breastfeeding session.

BMI, body mass index; CI, confidence interval; OR, odds ratio; SLE, stressful life event.

Discussion

Main findings

This study shows that the hands-on approach was frequently used by caregivers offering breastfeeding support and is associated with a more negative experience of the first breastfeeding session. The association remains significant even after adjustment for confounding factors such as BMI, parity, department where the first breastfeeding session took place, experience of giving birth, previous psychiatric contact, the woman's age, and the presence of a stressful life event in the previous 6 months. Use of the hands-on approach was found to be independently associated with primiparity, younger age, low level of education, smoking during pregnancy, postponed breastfeeding start, and high BMI.

Strengths and limitations

Among the strengths of this study are its population-based design, the large number of participating women, and the availability of information on series of possible confounders on an individual level. The response rate of 56% is in accordance with studies of similar nature. A nonresponse analysis for the whole of the UPPSAT cohort showed no difference in age, gestational length, delivery mode, or place of residence between responders and nonresponders, with the only difference being a slightly higher number of primiparas among responders. We have no reason to believe that responders differ from nonresponders in a way that could bias the associations between the hands-on approach and the experience of the first breastfeeding session.

A possible limitation of this study is that the mothers answered the questions on the first breastfeeding session 6 months postpartum, posing an eventual problem of recall bias. There is actually a lot happening during the first 6 months postpartum, and it is possible that the women's experiences during this period might affect their memories of the event and the way they answer questions about it. It has, on the other hand, been shown that women, a long time after giving birth, are capable of successfully recalling what happened during the birth process and the early hours postpartum.²¹ It is also possible to speculate that mothers who have a more negative attitude in general might have answered in a biased way concerning both the experience of the hands-on approach and the experience of the breastfeeding session. This association was, nevertheless, adjusted for both previous psychiatric contact and stressful life events in the past 6 months. The use of the hands-on approach cannot fully account for dissatisfaction with the first breastfeeding session because a majority of the women who had the hands-on approach had a positive experience of the first breastfeeding session. One could also speculate that overwhelming endorphins in the first hour or two postpartum might have made mothers who were able to breastfeed in those first hours more sanguine about any intervention, as long as they were able to breastfeed during that crucial early time. It could even be possible that some women found the hands-on approach helpful, but because the results of this study point to an overall association between the hands-on approach and a more negative experience of the first breastfeeding session, this method should be questioned and used only after careful consideration.

Interpretation

Despite the fact that earlier research has pointed out its negative effects,^9,11–13 the hands-on approach was found to be frequently used as breastfeeding support. Its use was associated with primiparity, postponed first breastfeeding session, and higher maternal BMI. The reasons for these associations can only be speculated upon but are possibly more related to preconceptions and prejudices in the medical staff than the mother's actual needs. The higher rate of the hands-on approach in primiparas is probably due to a wish to help inexperienced mothers establish breastfeeding.

The association between the hands-on approach and obstetric factors such as cesarean section and use of anesthesia during labor could be due to the fact that these factors cause separation and delay of the first breastfeeding session. These women are also more likely to postpone first breastfeeding so that this occurs in other places than the delivery ward (maternity, ward, operating theater, or neonatal intensive care unit), as reported by 26% of the women. The reasons why breastfeeding for the first time in the delivery ward rather than other places seems to have a positive impact on the breastfeeding experience are likely related to self-efficacy.²² In Uppsala University Hospital, approximately 20% of the women with a normal pregnancy and delivery return home as early as 6 hours after the delivery. If it is recommended that the woman stay in the maternity ward, it is more plausible that she has one or more obstetric complications and/or that she did not accomplish a successful first breastfeeding session in the delivery ward.

When considering possible negative effects of the hands-on approach, besides a theoretical increased risk for nosocomial infections in a hospital environment, this practice was shown in this study to be associated with a negative breastfeeding experience, possibly because of feelings of guilt and worthlessness.

Despite the fact that, because of the layout of the questionnaire, women did not formally have the possibility to describe why the first breastfeeding session was a negative experience, several of them felt so strongly about the issue that they left notes on the page margins. One mother first breastfeeding at the delivery ward receiving the hands-on approach wrote: “I wish I could have had more time so that the baby could have found my breasts on his own. It went so fast from the moment of birth until they helped him finding the breast.” Another woman wrote: “After a short while they used their hands.” Another mother experiencing the hands-on approach wrote: “In general, I thought that the staff was too pushy regarding breastfeeding. It was stressful.” The quotations in our study are in accordance and reflect other research results finding the hands-on approach as awkward and disrespectful⁹ and offending, influencing women's self-confidence.¹⁰ Gill¹² pointed out that self-confidence must be encouraged among newly delivered women, in order for them to breastfeed independently after leaving hospital care. Studies also point out that when mothers are taught to breastfeed in a way that makes them feel independent, the prevalence of rashes and sore nipples decreases.^11,13

This study investigates only the very first breastfeeding session, and this was clearly stated in the questionnaire. Mothers who, for some reason, had breastfeeding problems during their stay in the hospital would be more prone to receive the hands-on approach from the staff during their stay at the hospital, in order to find a way to breastfeed successfully. This approach, however, would not be expected to happen during the very first breastfeeding session, during which there is no evident explanation as to why the hands-on approach was used. One could speculate that these mothers have been trying to breastfeed for a while without success, which led the healthcare professionals to use their hands as a “quick fix.”

The relative impact of receiving the hands-on approach at a later time is unclear. More studies are needed in order to be able to investigate these questions.

Conclusions

This study indicates that despite evidence for negative effects, the hands-on approach is still frequently used. This practice was associated with a more negative experience of the first breastfeeding session, even after adjustment for possible confounders. Further research is needed in order to understand why caregivers choose the hands-on approach and to assess its long-term consequences. The results of this study need to be confirmed in other settings using a prospective design. If confirmed, the results should be disseminated among physicians, midwives, and assistants working in maternity units in order to possibly lead to revision of routines and guidelines in order to offer women the best evidence-based breastfeeding support.

Footnotes

Acknowledgments

The authors would like to thank all the participating women, as well as the staff at the Department of Obstetrics and Gynecology who helped with informing and recruiting patients as well as with the distribution of the questionnaires.

Disclosure Statement

No competing financial interests exist.

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