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Infant Behavior & Development 35 (2012) 264– 272

Contents lists available at SciVerse ScienceDirect

Infant Behavior and Development

ffects of postpartum anxiety disorders and depression on maternalelf-confidence

orinna Reck ∗, Daniela Noe, Jakob Gerstenlauer, Eva Stehleepartment of General Psychiatry, University of Heidelberg, Germany

r t i c l e i n f o

rticle history:eceived 25 May 2010eceived in revised form 26 January 2011ccepted 13 December 2011

eywords:aternal self-confidence

nxiety disorderepressionSM-IV-criteriauerpartumrevious psychiatric history

a b s t r a c t

Low maternal self-confidence may damage the early mother–infant relationship and nega-tively influence infant development. The goal of this study was to test whether a current andprevious history of DSM-IV anxiety and depressive disorders is associated with maternalself-confidence two weeks after delivery. Postpartum anxiety disorder and depression wasdiagnosed according to DSM-IV criteria in a community sample of 798 women. The datashowed a significant link between current postpartum anxiety and depressive disordersand maternal self-confidence. Furthermore, women with a depression or anxiety disor-der in their previous psychiatric history scored lower in maternal self-confidence. Thereis a need for appropriate preventive programmes to promote maternal self-confidence.With such programmes it is possible to prevent infant developmental disorders whichmight result from reduced feelings of maternal self-confidence and associated maternalinteraction behaviour.

© 2011 Elsevier Inc. All rights reserved.

. Introduction

Anxiety disorders and depression are the most frequently occurring mental illnesses in the postpartum period (Cooper &urray, 1998; Matthey, Barnett, Howie, & Kavannagh, 2003; Reck et al., 2008). Disturbances in the mother–child relationship

s well as emotional and cognitive deficits in infant development have repeatedly been shown to be related to postpartumepression (Cooper & Murray, 1997; Diego et al., 2002; Reck et al., 2004; Reck et al., 2006; Tronick & Reck, 2009). The fewndings available with respect to anxiety disorders also indicate an adverse influence of maternal anxiety disorders onhild development (Whaley, Pinto, & Sigman, 1999; Woodruff-Borden, Morrow, Bourland, & Cambron, 2002) as well as onarenting behaviour (Schneider et al., 2009).

In the context of understanding difficulties in the early mother–infant relationship as well as in infant developmentColeman & Karraker, 1997; Donovan & Leavitt, 1989; Hsu & Sung, 2008; Wells-Parker, Miller, & Toopping, 1990; Williamst al., 1987; Zahr, 1991), maternal self-confidence or maternal self-efficacy1 has become a central concept. A mother’s

eeling of self-confidence and self-efficacy is determined by a variety of factors, including contextual characteristics such asocial support, infant temperament, and maternal mental health (e.g. Leerkes & Burney, 2007). Maternal self-confidence isefined as the mother’s perception of her own ability to take care of the child and to correctly interpret the child’s signalsZahr, 1991). It governs adjustment to motherhood and is of relevance with respect to a positive mother–infant relationship

∗ Corresponding author at: Klinik für Allgemeine Psychiatrie, Zentrum für Psychosoziale Medizin, Vossstr. 2, 69115 Heidelberg, Germany.el.: +49 6221 564465; fax: +49 6221 561741.

E-mail address: corinna reck@med.uni-heidelberg.de (C. Reck).1 The term “maternal self-efficacy” (Teti & Gelfand, 1991) is often used in connection with “maternal confidence”. The two constructs have not been well

istinguished in the literature and are predominantly used as synonyms.

163-6383/$ – see front matter © 2011 Elsevier Inc. All rights reserved.oi:10.1016/j.infbeh.2011.12.005

C. Reck et al. / Infant Behavior & Development 35 (2012) 264– 272 265

Table 1Mean maternal self-confidence scores and demographic data for all groups.

Maternal self-confidence Age at birth (years) Number of children Educational levelb

Group M SD N M SD N M SD N 1 2 3 4 5

Controla 119.8 13.0 649 33.1 4.69 645 1.57 0.74 646 41 186 27 86 291Postpartum depression 113.0 15.4 38 30.7 5.36 38 1.53 0.56 38 3 18 1 5 10Postpartum anxiety 112.3 16.9 33 33.1 3.87 32 1.73 0.91 33 0 3 0 1 11Depression history 114.9 12.2 63 33.4 4.18 63 1.63 0.89 63 5 22 3 9 23Anxiety history 111.3 12.3 15 33.6 4.03 15 1.33 0.62 15 4 0 1 2 6Total 118.3 13.6 819 33.0 4.70 814 1.57 0.75 816 53 229 32 103 341

a Women without depression or anxiety disorders in past and present.

b Educational levels represent: 1, lower level secondary school leaving certificate (“Hauptschulabschluss”); 2, higher level secondary school leaving

certificate (“Realschulabschluss”); 3, vocational A levels (“Fachhochschulreife”); 4, A levels (“Hochschulreife”); 5, University degree.

(Williams et al., 1987). The construct of maternal self-efficacy stems from Teti and Gelfand (1991) and refers to the degreeto which the mother expects herself to be able to competently and effectively fulfil her parental role (Teti & Gelfand, 1991)and exert a positive influence on the behaviour and development of the child (Coleman, 1998). In addition to other factors,Bandura (1989) emphasises the significance of emotional states as a source for assessing self-efficacy. The more negative theemotional state, the more likely it is that failure will be expected and the lower assessments of one’s own self-efficacy willbe. Bandura’s assumption is in line with research that has linked depressive symptoms to maternal self-efficacy (Bornsteinet al., 2003; Cutrona & Troutman, 1986; Montgomery, 2000; Porter & Hsu, 2003; Teti & Gelfand, 1991). In the area of anxietyresearch, Hsu and Sung (2008) found a direct link between low maternal parenting self-efficacy and high maternal separationanxiety in a recent study of first-time mothers.

The influence of a previous history of depression and anxiety disorders on maternal functioning has so far been neglectedin most studies in the field of postpartum research, and the effects of previous symptoms and current symptoms are generallynot examined separately. Based on their findings concerning the importance of the quality of maternal affective expression inface-to-face interactions with their seven-month-old infants, Cohn and Tronick (1989) assumed that “depressed” interactionpatterns may continue even after remission and that effects of maternal depression are thus not limited to periods of acutesymptomatology. In fact, a recent study by Forbes, Cohn, Allen, and Lewinsohn (2004) showed that infants’ affect during astill-face condition was unrelated to parents’ current levels of depressive symptoms and that, in contrast, a lifetime historyof depression was predictive of elevated levels of infant negativity and less positive affective behaviour. Besides the above-described connection with affective expressions, a lifetime history of maternal depression also seems to be associated withincreased baseline and average infant cortisol levels during several stressor tasks (Brennan et al., 2008).

The present study aimed to gather data on the link between DSM-IV anxiety disorders and depression and maternalself-efficacy two weeks after delivery in a population-based German sample. Depression was assessed at both a dimensional(EPDS) and a categorical level (SCID-I). The purpose of the study was specifically to determine whether postpartum andprevious anxiety disorders and depression influenced maternal self-confidence two weeks postpartum. To the knowledgeof the authors, this is the first study to examine the effects of a previous history of DSM-IV anxiety disorders and depressionon maternal self-confidence in the postpartum period.

2. Method

2.1. Participants and study design

The study was conducted in South Germany in two middle-sized towns and their surroundings. The longitudinal, prospec-tive study was designed to gather comprehensive data on a German population sample of mothers within the first threemonths following delivery. Screening procedure is described elsewhere in detail (Reck et al., 2008). In this part of the study,we focus on the impact of anxiety disorders and depression on maternal self-efficacy two weeks postpartum. The study wasbased on a total sampling population of 812 women. These women were in-patients of delivery units and had given birthduring the period of December 2003 to February 2005.

All participants completed a demographic information sheet covering sociodemographic data such as age, number ofchildren and educational level (Table 1). All mothers took part in a screening procedure for detecting women with symptomsof clinical depression and anxiety (further details can be found in Reck et al. (2008)). Screening for depression was carriedout using the Patient Health Questionnaire-Depression (PHQ-D; Graefe, Zipfel, Herzog, & Loewe, 2004) and the Edinburghpostnatal depression scale (EPDS; Bergant, Nguyen, Ulmer, & Dapunt, 1998). Screening for anxiety disorders was performedusing the Anxiety-SCID-Screening (Wittchen et al., 1997) and the Anxiety Screening Questionnaire (ASQ-15; Wittchen &Boyer, 1998). Participants who reached a “critical score” in one of the four described screening instruments were additionally

interviewed in a second stage using the Structured Clinical Interview for current and previous DSM-IV, Axis I Disorders (SCID-I; Wittchen et al., 1997). Exclusion criteria for participation in the study included poor command of the spoken and writtenGerman language. Specific phobias were excluded due to their lack of clinical relevance. Furthermore, fourteen women

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66 C. Reck et al. / Infant Behavior & Development 35 (2012) 264– 272

ith current and seven with previous comorbid disorders (depression and anxiety disorders) were excluded from the datanalysis to ensure that the results were specific for each disorder.

Sample characteristics were as follows: women had a mean age of 33 years (SD = 4.7, range = 17–45) and a mean numberf 1.6 children (SD = 0.75, range = 1–5). 52.5% of the last-born infants who were relevant to the present study were males and7.5% were females. With regard to the mothers’ highest attained level of education, 6.7% had a “lower level secondary school

eaving certificate” (Hauptschule), 29.6% a “higher level secondary school leaving certificate” (Realschule), 4.3% “vocational levels”, 14.2% “A levels”, and 45.2% a “university degree”. Mean age at birth, number of children and education did notiffer significantly between the control group and all four treatment groups (sample characteristics compare Table 1). Weid not find significant differences in age at birth between the control group and all other groups (results of two-sidedwo sample t-test: Postpartum anxiety group: t = 1.531, df = 36.101, p = 0.135; Anxiety history group: t = 0.527, df = 13.528,

= 0.607; Postpartum depression group: t = 1.748, df = 41.35, p = 0.088; Depression history group: t = −0.095, df = 74.351, = 0.925). Neither did we find significant differences in the number of children between the control group and all otherroups (results of two-sided two sample t-test: Anxiety group: t = −0.372, df = 35.464, p = 0.712; Anxiety history group:

= −0.590, df = 13.331, p = 0.565; Postpartum depression group: t = −0.484, df = 44.431, p = 0.631; Depression history group: = −0.164, df = 77.483, p = 0.871.

The study protocol was approved by the independent ethics committee at the University Medical Faculty in Heidelberg.atient confidentiality was in no way breached. Written informed consent was obtained following a full explanation of therocedures involved.

.2. Measures

.2.1. Maternal self-confidence scale (LMSCS)Two weeks postpartum the LMSCS was applied for the assessment of mothers’ self-confidence. The items consist of

egative as well as positive subjective competence evaluations which are rated by women. The questionnaire comprises aotal of 24 items, each of which has six response options ranging from “strongly agree” (1) to “strongly disagree” (6). Theingle-item scores are summed to a total value. A total higher score indicates greater self-efficacy. For the scoring sometems are reversed (see Appendix for detailed information). With regard to reliability of the scale (internal consistency), anlpha coefficient of ̨ = .87 was found on the first day following delivery (Lips & Bloom, 1993). For the assessment of maternalelf-confidence in the current study, the LMSCS was translated into German. The quality of this translation was validatedy a back-translation into English which was conducted by a German-speaking, native English psychologist. Lips and Bloom1993) described in their study the following norms for their scale: scores below 89.49 and above 138.98 represented theower and upper 5% of the sample.

.2.2. Edinburgh postpartum depression scale (EPDS)The internationally well-established EPDS (Cox, Holden, & Sagovsky, 1987) is a self-rating scale for the screening of

ostpartum depression. It was developed and validated specifically for the postpartum period and assesses mental statever the past seven days. The scores for each individual answer correspond to the severity of the symptoms. The EPDS totalcore can range from 0 to 30. In the German version of the scale, a threshold value of 9.5 resulted in a sensitivity of .06,

specificity of 1.0 and a positive predictive value of 1.0 (Bergant et al., 1998). In the same version, the reliability analysisielded a value of .82 for the Guttman-Split half-reliability and a value of .81 for the ̨ coefficient. One can assume a high levelf statistical validation in the German version, especially with respect to the quality criteria validity and reliability. In thistudy, the EPDS was used for correlational analyses between severity of depressive symptoms and maternal self confidencend furthermore in the context of a screening procedure which has been described in detail elsewhere (Reck et al., 2008).articipants who reached in the screening procedure a critical score of 10 or more were additionally interviewed in a secondtage using the SCID-I.

.2.3. Structured clinical interview for DSM-IV axis I disorders (SCID-I)The SCID-I (Wittchen et al., 1997) is a semi-structured, economic, efficient, and reliable instrument for the measurement

nd diagnosis of selected Axis I mental syndromes and disorders according to the criteria of the Diagnostic and Statisticalanual of Mental Disorders (DSM-IV; Saß, Wittchen, & Zaudig, 1994). It was additionally applied in the first three months

ostpartum given the occurrence of clinically relevant symptoms in the course of screening with the EPDS (for furtheretails see Reck et al., 2008). Since a minimum symptom duration of six months is necessary for a diagnosis of generalisednxiety disorder, it is not possible for a de novo onset of generalised anxiety disorder to occur in the postpartum period.or this reason, women meeting the criteria of generalised anxiety disorder in the three-month postpartum period who had

minimum symptom duration of two weeks within the last four (analogous to the criteria for a depressive episode) wereiagnosed with acute adjustment disorder with anxiety (AADA; Matthey et al., 2003). Additional the full mood and anxietyodule including the assessment of previous history of psychiatric disorders was applied.

.2.4. Demographic information formEach participant completed a demographic information form, comprising sociodemographic and obstetric data such as

ge, number of children, and educational level as well as delivery mode and pregnancy experience. The research assistants

C. Reck et al. / Infant Behavior & Development 35 (2012) 264– 272 267

who administered the screening instruments and conducted the SCID-I had received training in order to ensure reliability.For the purpose of ensuring maintained reliability, continuous checks were made throughout the study.

2.3. Statistical analyses

Reliability of the German LMSCS was tested using Cronbach’s Alpha. The influence of sociodemographic variables (genderof last-born child, age and education of the mother) was examined using correlation analyses and t-tests. The relationshipbetween depression severity (measured using the EPDS) and LMSCS scores was analysed using Spearman rank correlations.We compared the LMSCS scores of the clinical groups with those of the control group using Cohen’s d as a measure of effectsize. Cohen’s d measures the effect of a treatment relative to a control treatment by dividing the difference in group meansby the pooled standard deviation of both groups. Here, we choose the group of subjects without any relevant diagnosis,neither current nor historical, as control group. Therefore, negative effect sizes indicate that the clinical group has a lowerscore than the control group of unaffected persons. Although it depends on the research subject at hand, absolute values ofthe effect size of 0.25, 0.5, and 0.80 are generally regarded as “small”, “medium”, and “large” effects, respectively (Cohen,1969). Due to the problems associated with unbalanced sample sizes (Laczo, Sackett, Bobko, & Cortina, 2005), we used thecorrection factor J for unbalanced sample sizes when calculating the standardised effect size (Cohen, 1969). In order to assessthe uncertainty of the effect-size estimate, we calculated both standard errors using an analytical formula as presented byHedges and Olkin (1985, page 86 as cited in Laczo et al.) and 95% confidence intervals using a bootstrap resampling approach.All computations were conducted using the statistics program R Version 2.8.0 (R Development Team, 2008).

3. Results

3.1. Reliability of the questionnaire

According to Nunally and Bernstein (1994), questionnaires with a Cronbach’s alpha above 0.6 can be considered reliablescreening tools. We found a Cronbach’s alpha of ̨ = 0.87 (N = 798) for the LMSCS questionnaire. This high alpha value thusindicates that the LMSCS is a highly efficient and precise tool for the assessment of maternal self-confidence.

3.2. Sociodemographic covariates: mothers’ age and educational level, sex of child

There was no significant relationship between LMSCS scores and mothers’ age (rs = −0.038, p = 0.29), number of children(rs = −0.01, p = 0.78), mothers’ level of education (F = 0.1652, p = 0.96), or sex of the (last-born) child (t = −0.28, p = 0.78). Dueto the lack of observed effects of these sociodemographic variables, they were not considered in subsequent analyses.

3.3. Distribution of maternal self-confidence sum scores

Sum scores in maternal self-confidence ranged between 47 and 144, with a mean of M = 118.6 (SD = 13.4). The first andthird quartiles were 111.0 and 129.0. The total sample size was N = 798.

3.4. Relationship between maternal self-confidence and depression scores (EPDS)

There was a strong negative Spearman rank correlation between maternal self-confidence and depression scores,rs = −0.55, p < 0.001.

3.5. Links between maternal self-confidence and anxiety disorders and depression (SCID-I)

All four groups (current and previous anxiety disorders and current and previous depression) had a significantly negativeimpact on maternal self-confidence, with maternal self-confidence proving lower as compared with the control group (Fig. 1,summary statistics of raw data are shown in Table 1 for all groups).

By using the Cohen’s d effect size measure we were able to compare the effect of current and past diagnoses on maternalself-confidence despite unbalanced sample sizes. All diagnoses significantly (as CIs did not overlap with zero) decreasedmaternal self-confidence in comparison to the healthy control group. For all comparisons we found strong effect sizesaccording to criteria of Cohen (1969). An anxiety disorder diagnosis in the past had the strongest negative impact on maternalself-confidence (d = −2.34, 95% CI: −2.67 to −2.12, SE = 0.072), followed by a current anxiety disorder (d = −2.06, 95% CI: −2.14

to −1.75, SE = 0.035), current depression disorders (d = −1.88, 95% CI: −1.99 to −1.63, SE = 0.030), and previous depressiondisorders(d = −1.36, 95% CI: −1.52 to −1.25, SE = 0.019). Interestingly, a history of anxiety disorders had a more negativeimpact than current anxiety diagnoses (confidence intervals overlapped only slightly). In contrast, the impact of currentdepression was stronger than that of depression disorders in the past.

268 C. Reck et al. / Infant Behavior & Development 35 (2012) 264– 272

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ig. 1. Distribution of maternal self confidence scores for all groups. Boxplots show median (dark line in box), first to third quartile (upper and lower edges ofhe box), and the vertical dashed lines show either the maximum numbers or 1.5 times the interquartile range. Labels on the x-axis are: Anxiety, postpartumnxiety group; Anxiety history, anxiety history group; Depression, postpartum depression group; Depression history, depression history group.

. Discussion

The current study represents the first German investigation of maternal self-confidence based on a community sample.ith the exception of the German translation of the LMSCS (Reck & Stehle, 2008), there have been no questionnaires available

n German for the assessment of maternal self-confidence. Furthermore, to the knowledge of the authors, the present studyepresents the very first investigation of the link between maternal self-confidence and postpartum and previous anxietyisorders/depression according to DSM-IV-criteria. The results thus provide new data on the influence of current as wells previous depression and anxiety disorders on maternal self-confidence. We further studied the link between severity ofostpartum depressive symptoms, assessed using the EPDS, and maternal self-confidence. Finally, we also evaluated theociodemographic correlates of mothers’ LMSCS scores.

We found the LMSCS to be a reliable instrument, with an internal consistency of ̨ = 0.87. Concerning the relation-hip between maternal self-confidence and DSM-IV anxiety disorders and depression we found significantly lower LMSCScores in women with these psychiatric disorders as compared with healthy controls. These results confirm the relationshipetween depressive symptoms and maternal self-efficacy found in other studies (Bornstein et al., 2003; Cutrona & Troutman,986; Montgomery, 2000; Porter & Hsu, 2003; Teti & Gelfand, 1991). We also found a negative correlation between mater-al self-confidence and postpartum depressive symptoms, with higher EPDS scores being accompanied by lower LMSCScores. Our results indicating a link between anxiety disorders and maternal self-confidence are also in line with a studyonducted by Sayil, Güre, and Ucanok (2006), in which lower self-esteem and self-efficacy in the prenatal period were signif-cantly associated with prenatal maternal anxiety. With regard to the influence of previous psychiatric history on maternalelf-confidence, we found that previous anxiety disorders and depression both had a negative impact on maternal self-onfidence two weeks postpartum. Furthermore and unexpectedly, past-history anxiety was found to have the strongestmpact on maternal self-efficacy. This finding suggests that even in the case of a current full remission, a previous historyf anxiety disorders and depression leads to negatively altered self-assessments with respect to maternal self-confidence.hese results contradict the findings of a study by Logsdon, Wisner, and Hanusa (2009), in which remission of depressiveymptoms was associated with significant benefits for overall functioning and gratification in the maternal role. They foundhat self-efficacy scores were stable in women with remitted symptoms and worsened in women with non-remitted symp-oms. Based on the data available, however, it cannot be concluded whether the two groups actually differed with respecto their observed competence in interacting with their child. In this context, Weinberg and Tronick (1998), for example,ere able to demonstrate in a retrospective cross-sectional study that mothers who received antidepressant treatment and

howed a remission of symptoms continued to exhibit dysfunctional behaviours which were comparable to those describedn the literature for untreated depressive mothers when interacting with their infants. In line with this, Zahr (1991) showedhat there was no relationship between observed maternal behaviours and skills and mothers’ perceptions of confidence.

ith regard to the impact of past anxiety disorders on maternal self-confidence no data are available.

C. Reck et al. / Infant Behavior & Development 35 (2012) 264– 272 269

No significant effects of sociodemographic variables were found for maternal self-confidence. Our data therefore do notconfirm the findings by Conrad, Gross, Fogg, and Ruchala (1992) that older mothers possess higher maternal self-confidencethan younger mothers. In contrast to the results of Montgomery (2000), our data also failed to reveal an effect of number ofchildren on maternal self-confidence.

Several limitations of our study should be considered. For reasons of time economy, it was not possible to assess theimpact of other potentially significant psychosocial variables. The additional application of measures of life events, socialsupport, and quality of marital relationship may have provided important additional information. Furthermore, the problemsassociated with retrospective data collection applied with respect to the examination of previous psychiatric history. Allassessments in the present study were conducted in the postpartum period and were thus subject to a retrospective reportingbias with regard to their previous history of psychiatric disorders. It should also be mentioned that it was not possible toscreen all women who gave birth in the respective clinics and that those women who did not give birth in a clinic wereautomatically excluded. Furthermore, it must be noted that maternal self-confidence was not assessed using a clinicalinterview. Future studies should perform a validation of the German version of the LMSCS, including mothers with impairedmaternal self-confidence in order to determine whether the LMSCS is able to detect clinically significant self-confidenceimpairments. A further limitation of the present study can be seen in the possible influence of answer tendencies in terms ofsocial desirability. It is plausible that a number of participants failed to answer questions in an honest manner on account ofthe shame-inducing nature of the research topic under investigation. In order to control for such answer tendencies, futurestudies of maternal self-confidence should ensure that an appropriate control measure like the Marlowe-Crowne SocialDesirability Scale (Crowne & Marlowe, 1960) is integrated.

To conclude, the present findings provide new insights into the relationship between maternal self-confidence and DSM-IV depression and anxiety disorders. Research in clinical samples would seem to be very important for the developmentand evaluation of specific interventions targeting maternal self-efficacy (Sanders & Woolley, 2005; Svensson, Barclay, &Cooke, 2009). Specific interventions should be implemented within the first few weeks postpartum in order to preventdevelopmental disorders which may result from reduced feelings of maternal self-efficacy in the context of current andprevious anxiety disorders and depression. In future investigations of the relationship between maternal self-confidenceand postpartum depression/anxiety disorders, particular attention should be paid to the impact of previous anxiety dis-orders on maternal self-confidence. Furthermore, prospective studies should commence during pregnancy and include anassessment of observed maternal interaction behaviour as well as the parenting context in the postpartum period. Leerkesand Burney (2007) showed that prenatal maternal efficacy is a function of both prenatal characteristics and the parentingcontext. To date, there have been no prospective studies of maternal self-confidence in clinical groups classified accordingto DSM-IV disorders during pregnancy and the postpartum period. Appropriate preventive programmes are required whichcommence during pregnancy and accompany women throughout the first three months and which target the subjectiveassessment of maternal self-confidence and its potential relationship to objective maternal interactional behaviour followingdelivery.

Role of funding source

Study funding was provided by a grant from the Programme of Research Support at the University Medical Faculty, Hei-delberg (funding period: 2003–2004); the University Medical Faculty played no further role in the design of the study;the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the paper forpublication.

Conflict of interest

We confirm that there are no conflicts of interest, including specific financial interests or relationships and affiliationsrelevant to the subject of our manuscript.

Acknowledgements

First and foremost, we would like to express out thanks to the women who were prepared to take part in the study. Our

thanks also go to the maternity clinics and their staff in Heidelberg (St. Josef’s Hospital, Saint Elisabeth’s Hospital, SalemHospital, and the Gynaecological Clinic at the University of Heidelberg) as well as participating clinics in Darmstadt (Alice-Hospital and Darmstadt Hospital) for their willingness to cooperate and their support in recruiting patients. Further thanksto Dawn Girlich for her help in manuscript preparation.

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