Perinatal Grief Scale (PGS)

1. Abstract

The Perinatal Grief Scale (PGS) is one of the most widely utilized, rigorously validated, and clinically informative self-report psychometric instruments designed to assess psychological distress and bereavement following perinatal loss. Originally developed as an 84-item instrument by Lori J. Toedter, Judith N. Lasker, and John M. Alhadeff in 1988, the scale was refined into a psychometrically robust, standardized 33-item short form by Louise Potvin, Judith N. Lasker, and Lori J. Toedter in 1989. The PGS specifically operationalizes the multidimensional phenomena of grief following miscarriage, stillbirth, ectopic pregnancy, and neonatal death. The instrument captures three distinct but intercorrelated dimensions of grief: Active Grief (acute emotional reactions, tearfulness, yearning, and physical sadness), Difficulty Coping (social withdrawal, functional impairment, cognitive disruption, and interpersonal friction), and Despair (existential crisis, profound self-blame, worthlessness, and prolonged demoralization). Items are rated on a 5-point Likert scale ranging from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”). Extensive global psychometric evaluations have demonstrated exceptional internal consistency, with total scale Cronbach’s alpha coefficients routinely exceeding α = .92 to .96, and subscale coefficients ranging from α = .80 to .92. Confirmatory factor analyses across diverse multinational cohorts have corroborated its triadic oblique factor architecture, verifying structural invariance across gestational age, parental gender, and temporal distances from the loss event. Furthermore, the PGS exhibits robust convergent validity with standardized instruments measuring major depressive disorder, generalized anxiety, post-traumatic stress, and complicated grief, while retaining discriminant validity from generalized negative affectivity. Clinically, total scores exceeding 90 to 91 are widely established as identifying bereaved parents at elevated risk for chronic psychiatric morbidity, making the PGS an indispensable tool in reproductive psychology, obstetrics, psychiatric epidemiology, and clinical intervention trials.

2. Keywords

Perinatal Grief Scale, PGS, perinatal bereavement, pregnancy loss, stillbirth, miscarriage, neonatal death, psychometrics, grief measurement, Active Grief, Difficulty Coping, Despair, complicated grief, reproductive psychology

3. Authors

The Perinatal Grief Scale was conceptualized, developed, and empirically validated through a sustained collaborative partnership among leading researchers in behavioral medicine, sociology, and quantitative psychometrics:

• Lori J. Toedter, Ph.D. — Professor Emerita of Psychology, Department of Psychology, Moravian University (formerly Moravian College), Bethlehem, Pennsylvania, United States. Dr. Toedter’s expertise centers on quantitative methodology, health psychology, and the long-term cognitive and emotional outcomes associated with reproductive trauma.
• Judith N. Lasker, Ph.D. — NEH M. Scott Professor Emerita of Sociology, Department of Sociology and Anthropology, Lehigh University, Bethlehem, Pennsylvania, United States. Dr. Lasker is an internationally recognized medical sociologist whose pioneering investigations have elucidated the socio-environmental determinants of women’s reproductive health, perinatal bereavement, and healthcare delivery systems.
• John M. Alhadeff, Ph.D. — Former Professor of Chemistry and Health Sciences, Lehigh University, Bethlehem, Pennsylvania, United States. Dr. Alhadeff contributed fundamentally to the initial longitudinal cohort studies and statistical parameterization of the original 84-item instrument.
• Louise M. Potvin, Ph.D. — Professor, Département de Médecine Sociale et Préventive, École de Santé Publique, Université de Montréal, Montreal, Quebec, Canada. Dr. Potvin led the rigorous item-reduction and psychometric refinement procedures that established the universally implemented 33-item short form of the PGS.

4. Purpose

The primary clinical and epidemiological purpose of the Perinatal Grief Scale (PGS) is to provide an empirically grounded, nuanced, and standardized methodology for quantifying the magnitude, trajectory, and qualitative dimensions of grief following the loss of an unborn or newborn child. Perinatal loss — comprising spontaneous abortion (miscarriage), induced abortion for fetal anomalies, ectopic pregnancy, intrauterine fetal demise (stillbirth), and early neonatal death — has historically occupied a unique and ambiguous space within psychiatric nosology. Unlike conventional interpersonal bereavement, perinatal loss often involves the loss of a projected future, an unrealized developmental identity, and an attachment bond formed in the absence of shared autobiographical memories. Furthermore, societal invalidation frequently renders perinatal loss a prime manifestation of disenfranchised grief, wherein bereaved parents are denied the traditional mourning rituals, social support systems, and institutional recognition afforded to other deaths.

Prior to the introduction of the PGS, clinicians and behavioral researchers frequently relied on generic bereavement batteries — such as the Texas Revised Inventory of Grief (TRIG) or the Grief Experience Inventory (GEI) — or generalized psychiatric symptom checklists, including the Beck Depression Inventory (BDI) and the Symptom Checklist-90-R (SCL-90-R). While informative regarding gross psychopathology, these instruments fundamentally failed to capture the idiosyncratic clinical manifestations of pregnancy loss, such as profound maternal somatic sensations, phantom fetal movements, intense feelings of physical failure or biological inadequacy, pervasive guilt centered on gestational behaviors, and severe existential alienation surrounding reproductive capacity.

The PGS bridges this diagnostic chasm by serving multiple complementary purposes across clinical, psychiatric, and research settings:

• Diagnostic Screening and Triage: The scale enables perinatal nurses, obstetricians, social workers, and clinical psychologists to rapidly screen parents following loss and identify those manifesting atypical, protracted, or pathological mourning processes requiring secondary and tertiary psychiatric interventions.
• Differentiation of Grief from Major Depressive Disorder: By delineating normal yearning and sadness from maladaptive social withdrawal and clinical despair, the PGS assists clinicians in distinguishing uncomplicated acute perinatal grief from emergent clinical depression or complicated grief disorders.
• Longitudinal Outcome Tracking: In intervention research, the PGS serves as a gold-standard primary outcome measure for evaluating the efficacy of bereavement counseling, cognitive-behavioral grief interventions, peer support programs, and hospital-based palliative bereavement protocols across months and years post-loss.
• Cross-Parental and Dyadic Comparison: The instrument facilitates the systematic comparison of grief trajectories between gestational and non-gestational parents, elucidating how discrepant mourning expressions can generate dyadic distress, marital conflict, or relationship dissolution.

5. Psychological Construct

The psychological construct underlying the Perinatal Grief Scale is multidimensional bereavement distress specific to the loss of a child during gestation or the immediate postpartum epoch. In their foundational psychometric investigations, Toedter, Lasker, and Potvin established that perinatal bereavement cannot be reduced to a unidimensional severity index; rather, it manifests through a hierarchically organized, three-dimensional construct reflecting progressive depths of psychological and functional vulnerability:

1. Active Grief

Active Grief represents the universal, emotionally normative, and biologically primed response to the acute severance of an attachment bond. Comprising 11 items (e.g., Item 1: “I feel depressed”; Item 10: “I am grieving for the baby”; Item 16: “I very much miss the baby”; Item 25: “I cry when I think about him/her”), this dimension reflects acute sadness, explicit mourning, persistent yearning, emotional crying, and an urgent psychological need to verbalize and process the reality of the loss. Active grief encapsulates the visceral awareness of loss without necessarily indicating structural personality breakdown or pathological cognitive distortions. High scores on this subscale reflect intense current affective engagement with the mourning process, which, in the acute aftermath of loss, represents a healthy, adaptive effort to integrate the reality of the death.

2. Difficulty Coping

Difficulty Coping captures the functional, cognitive, and interpersonal sequelae of the loss, reflecting the parent’s struggle to maintain normal social equilibrium and daily functional competence. Comprising 11 items (e.g., Item 2: “I find it hard to get along with certain people”; Item 5: “I can’t keep up with my usual activities”; Item 17: “I get cross at my friends & relatives more than I should”; Item 29: “I find it difficult to make decisions since the baby died”), this dimension measures secondary behavioral impairment. Bereaved individuals scoring high on Difficulty Coping exhibit cognitive paralysis, emotional lability, decision-making deficits, irritability, social avoidance, and interpersonal friction — particularly directed at peers, friends, or family members whose insensitivity or presence of healthy infants triggers agonizing reminders of the loss. This subscale marks the transition from purely private emotional suffering to external social and occupational dysfunction.

3. Despair

Despair represents the deepest, most pernicious, and clinically dangerous dimension of the perinatal grief construct. Comprising 11 items (e.g., Item 6: “I feel guilty when I think about the baby”; Item 18: “The best part of me died with the baby”; Item 21: “I blame myself for the baby’s death”; Item 24: “I feel worthless since he/she died”; Item 27: “It is safer not to love”; Item 33: “Being a bereaved parent means being a second class citizen”), Despair quantifies existential shattering, pervasive guilt, profound self-blame, worthlessness, and structural demoralization. Whereas Active Grief represents sorrow over the deceased infant, Despair represents the total collapse of self-esteem, the internal destruction of meaning, and the pervasive conviction that the self is permanently damaged, biologically defective, or morally culpable for the child’s demise. Elevated scores on the Despair subscale correlate strongly with suicidal ideation, prolonged complicated grief, clinical major depression, and permanent identity fragmentation, serving as the primary psychometric driver of the scale’s psychiatric risk categorization.

6. Theoretical Framework

The construction and validation of the Perinatal Grief Scale are anchored in several foundational paradigms within developmental psychology, psychiatric sociology, and modern suicidology/thanatology:

Attachment Theory

The primary theoretical bedrock of the PGS is John Bowlby‘s classical Attachment Theory, complemented by the empirical bereavement models of Colin Murray Parkes. Bowlby posited that attachment behaviors are instinctive evolutionary systems designed to maintain proximity to a protective figure. In parental bereavement, however, the attachment dynamic is bidirectional: parents develop an intense, neurobiologically supported caregiving system focused on the unborn child. Ultrasound imaging, prenatal testing, fetal movement (quickening), and nursery preparation solidify an internal working model of the infant as an autonomous relational entity. When pregnancy ends abruptly in death, the maternal and paternal caregiving systems are catastrophically severed without physical resolution. The searching, yearning, crying, and somatic distress operationalized within the Active Grief subscale directly mirror Bowlby’s prototypical “protest” and “yearning/searching” phases of grief.

Cognitive-Existential Models and Meaning Reconstruction

The progression from Active Grief to Difficulty Coping and Despair aligns theoretically with Robert A. Neimeyer‘s meaning reconstruction framework and Ronnie Janoff-Bulman‘s theory of shattered assumptions. Janoff-Bulman posited that traumatic events violently dismantle three core fundamental assumptions: (1) the world is benevolent, (2) the world is meaningful, and (3) the self is worthy. In perinatal loss, these foundational cognitive schemas are obliterated. Items such as “I feel unprotected in a dangerous world since he/she died” (Item 12) and “It is safer not to love” (Item 27) directly reflect the dissolution of perceived environmental benevolence and defensive emotional detachment. Similarly, items tapping self-blame and worthlessness reflect catastrophic cognitive distortions wherein parents internalize the biological failure of the pregnancy as a definitive moral indictment of their parental competence.

Disenfranchised Grief and Sociological Stigmatization

Sociologically, the scale operationalizes Kenneth J. Doka‘s concept of disenfranchised grief. Unlike adult bereavement, where social rituals (funerals, condolence visits, bereavement leave) validate the survivor’s status, perinatal death is frequently trivialized by healthcare providers and social networks with minimizing aphorisms (e.g., “You can have another one,” “It was for the best”). This lack of social consensus induces profound alienation, encapsulated in the subscale items addressing feeling like a “second class citizen” (Item 33) and feeling “somewhat apart and remote even among friends” (Item 26). The inability to locate external communal validation forces the grieving process inward, accelerating functional decompensation and depressive despair.

7. Validity

The psychometric validity of the Perinatal Grief Scale has been subjected to exhaustive empirical evaluation across longitudinal cohorts, cross-sectional epidemiological studies, and cross-cultural adaptations over three decades:

Content and Face Validity

Initial content validity was rigorously established by Toedter, Lasker, and Alhadeff (1988) through the analysis of qualitative interviews with hundreds of bereaved mothers and fathers, consultations with perinatal loss support groups, and panels of maternal-fetal medicine specialists and bereavement psychologists. The initial 84 items reflected the complete spectrum of phenomenological expressions reported by bereaved individuals. In 1989, Potvin and colleagues utilized rigorous item-total correlations, factor loadings, and content redundancy analyses to extract the 33 most robust, conceptually pure items, ensuring that the 11 items per subscale fully preserved the domain coverage of the original instrument without excessive participant burden.

Construct and Factorial Validity

Construct validity is substantiated by the scale’s invariant three-factor oblique structure across independent international samples. Factor loadings across studies consistently demonstrate that items possess substantial structural coefficients (> .50 to .85) on their designated latent factors. In meta-analytic and comparative validation studies published by Toedter, Lasker, and Janssen (2001), structural equation modeling demonstrated that the three-factor model consistently outperforms single-factor or two-factor models across American, Canadian, British, German, and Spanish cohorts.

Convergent and Concurrent Validity

The convergent validity of the PGS is evidenced by strong, statistically significant correlations with established psychiatric indices:

• Depression: Total PGS scores correlate robustly with the Beck Depression Inventory (BDI) and the Edinburgh Postnatal Depression Scale (EPDS), with Pearson coefficients ranging between r = .65 and r = .81 (p < .001). As theoretically predicted, the Despair subscale demonstrates the highest correlation with depressive severity (r > .75).
• Anxiety and General Distress: Strong correlations have been consistently demonstrated with the State-Trait Anxiety Inventory (STAI; r = .60 to .72) and the General Severity Index (GSI) of the Symptom Checklist-90-R (SCL-90-R; r = .68 to .78).
• Post-Traumatic Stress: Correlations with the Impact of Event Scale-Revised (IES-R) range from r = .62 to .75, demonstrating that intense perinatal grief overlaps with traumatic intrusive and avoidant stress responses.

Discriminant Validity

The PGS demonstrates clear discriminant validity by distinguishing between normal grief reactions and pervasive, generalized psychopathology. Longitudinal data demonstrate that whereas Active Grief scores decline naturally and significantly across a 2-year post-loss period in non-complicated trajectories, Despair scores remain stable only among individuals exhibiting clinical depression or severe personality decompensation. Furthermore, the PGS successfully discriminates between bereaved and non-bereaved postpartum parents, exhibiting negligible baseline scores among parents with healthy full-term deliveries.

Predictive and Criterion Validity

The scale possesses high predictive validity regarding long-term psychiatric morbidity. In longitudinal research by Lasker and Toedter, parents exhibiting a total PGS score > 90 at 2 months post-loss showed an 80% probability of meeting diagnostic criteria for Major Depressive Disorder or Generalized Anxiety Disorder at 12 and 24 months post-loss. Thus, the PGS acts as a highly sensitive prognostic screening tool.

8. Reliability

The Perinatal Grief Scale has demonstrated exemplary reliability metrics across dozens of peer-reviewed empirical studies worldwide:

Internal Consistency

In the seminal 33-item validation investigation by Potvin, Lasker, and Toedter (1989), the total scale demonstrated an exceptional Cronbach’s alpha of α = .95. Reliability estimates for the three individual 11-item subscales were uniformly high:

• Active Grief: α = .92
• Difficulty Coping: α = .91
• Despair: α = .86

Subsequent international validation studies have mirrored these findings with remarkable precision. In an extensive multinational meta-analysis summarizing over a decade of research across 22 independent studies (Toedter, Lasker, & Janssen, 2001), total PGS Cronbach’s alphas ranged from .92 to .96. The Active Grief subscale maintained internal consistency alphas between .86 and .92; Difficulty Coping ranged from .81 to .91; and Despair ranged from .82 to .89. In a large Spanish validation study (Fernández-Sánchez et al., 2012), the total scale achieved α = .94, with subscale alphas of .86 (Active Grief), .82 (Difficulty Coping), and .83 (Despair). In a German cohort (Gawron et al., 2015), the overall internal consistency was α = .95.

Test-Retest Reliability and Stability

Because grief is an evolving emotional process, test-retest reliability must be evaluated over brief intervals to avoid confounding psychometric stability with natural longitudinal recovery. Over a 2-to-4-week test-retest window, intraclass correlation coefficients (ICC) and Pearson stability coefficients for the total PGS have consistently ranged between r = .87 and .93, indicating exceptional temporal stability. Over longer intervals (e.g., 6 to 12 months), stability coefficients remain moderately high (r = .55 to .70), accurately reflecting the gradual, non-linear dissipation of acute grief symptomatology.

Standard Error of Measurement

The Standard Error of Measurement (SEM) for the total 33-item scale is remarkably small, typically calculated between 2.8 and 3.4 points on the 33–165 score range. This narrow margin demonstrates that individual respondent fluctuations reflect true variance in grief magnitude rather than instrument-induced measurement error.

9. Factor Analysis

The structural validity of the Perinatal Grief Scale has been definitively established through sequential Exploratory Factor Analyses (EFA) and Confirmatory Factor Analyses (CFA):

Exploratory Factor Analysis (EFA)

During the initial development of the 84-item instrument, Toedter et al. (1988) subjected parent responses to principal component analysis with oblique (Promax) and orthogonal (Varimax) rotations. Oblique rotation was theoretically preferred given that genuine psychological dimensions of grief are inherently intercorrelated. Three dominant eigenvalues significantly exceeded unity, accounting for the primary share of total variance. The items loading cleanly onto Factor 1 reflected direct, outward emotional expressions of mourning (Active Grief); items on Factor 2 captured functional, cognitive, and social friction (Difficulty Coping); and items on Factor 3 reflected existential devastation, self-condemnation, and severe demoralization (Despair).

In 1989, Potvin, Lasker, and Toedter systematically culled the 84 items down to 33 by selecting the 11 items per factor that demonstrated the highest factor loadings (consistently > .55), the lowest cross-loadings (< .30), and the greatest conceptual breadth. A secondary EFA on this refined 33-item set verified that the three-factor solution accounted for 54.3% of the total variance.

Confirmatory Factor Analysis (CFA)

Subsequent psychometric investigations have applied rigorous CFA modeling to assess construct validity and structural invariance across populations. Competing structural models have been routinely evaluated:

1. Unidimensional Model: A single general “Grief” factor on which all 33 items load.
2. Three-Factor Independent Model: Active Grief, Difficulty Coping, and Despair modeled as mutually orthogonal (uncorrelated) latent constructs.
3. Three-Factor Correlated (Oblique) Model: Active Grief, Difficulty Coping, and Despair modeled as distinct but intercorrelated latent factors.
4. Hierarchical / Second-Order Model: A second-order general Perinatal Grief factor that accounts for the covariance among the three first-order factors.

Across multiple investigations, the Three-Factor Correlated Model and the Hierarchical Second-Order Model have consistently demonstrated superior fit indices compared to single-factor or orthogonal alternatives. Standard goodness-of-fit indices reported in contemporary CFA studies include:

• Comparative Fit Index (CFI): .92 – .96 (exceeding the standard .90 threshold for acceptable fit)
• Tucker-Lewis Index (TLI): .91 – .95
• Root Mean Square Error of Approximation (RMSEA): .045 – .062 (with 90% confidence intervals below .070)
• Standardized Root Mean Square Residual (SRMR): .048 – .058
• Chi-Square to Degrees of Freedom Ratio (χ²/df): 1.75 – 2.30

Factor intercorrelations among the three latent dimensions are typically moderate to high: r between Active Grief and Difficulty Coping ranges from .68 to .76; r between Difficulty Coping and Despair ranges from .72 to .81; and r between Active Grief and Despair ranges from .58 to .69. These structural parameters confirm that while the three dimensions tap a unified underlying crisis of bereavement, they retain distinct psychometric identities essential for fine-grained clinical assessment.

10. Instrument / Measurement Tool

• Instrument Name: Perinatal Grief Scale (PGS) — Short Version
• Alternative Titles: Shortened Perinatal Grief Scale (SPGS), Potvin-Lasker-Toedter Grief Scale
• Measurement Paradigm: Multi-item, self-report psychological rating inventory
• Target Population: Adult women and men who have experienced perinatal loss through miscarriage, induced abortion for genetic or medical indications, ectopic pregnancy, intrauterine fetal demise (stillbirth), or early neonatal death
• Total Number of Items: 33 items
• Subscales and Dimensional Allocation:
  • Active Grief (11 items): Items 1, 4, 7, 10, 13, 16, 19, 22, 25, 28, and 31
  • Difficulty Coping (11 items): Items 2, 5, 8, 11, 14, 17, 20, 23, 26, 29, and 32
  • Despair (11 items): Items 3, 6, 9, 12, 15, 18, 21, 24, 27, 30, and 33
• Response Scale: 5-point Likert-type scale scored as follows:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Neither Agree nor Disagree
  • 4 = Agree
  • 5 = Strongly Agree
• Scoring and Transformation Protocols:
  • Reverse-Scored Items: Items 11 and 32 are designated as reverse-scored items in standard scoring protocols. For these items, scoring must be inverted prior to aggregation: 1 becomes 5, 2 becomes 4, 3 remains 3, 4 becomes 2, and 5 becomes 1.
  • Subscale Scores: Sum the raw (or reverse-coded) scores of the 11 items within each respective subscale. Each subscale yields a theoretical score ranging from 11 to 55.
  • Total Score: Sum the three subscales (or all 33 individual items). The total PGS score yields a theoretical minimum of 33 and a maximum of 165.
• Clinical Interpretation and Cut-off Scores:
  • Total Score < 60: Typical/low mourning distress; healthy adaptive response.
  • Total Score 60 – 90: Moderate grief; normative bereavement reactions requiring compassionate monitoring and supportive care.
  • Total Score > 90 (or > 91): Standard empirical clinical cut-off indicating severe bereavement distress, high vulnerability to major depression, anxiety disorders, or complicated grief, and a clear indication for formal psychiatric evaluation.
  • Despair Subscale Score > 30: Specifically denotes profound self-condemnation, clinical hopelessness, and elevated suicide risk, warranting immediate clinical assessment.
• Administration Time: Approximately 8 to 12 minutes to complete independently.

11. Permissions & Fee and Test Year

• Initial Publication Year: 1988 (Original 84-item instrument); 1989 (Standardized 33-item short form).
• Copyright and Intellectual Property: The Perinatal Grief Scale is copyrighted by its original developers (Judith N. Lasker, Lori J. Toedter, and Louise M. Potvin) and the respective academic journals in which the validation studies appeared (the American Orthopsychiatric Association / American Psychological Association; Springer Science+Business Media).
• Usage Terms and Commercial Fee: The PGS is considered an open-access psychometric instrument for non-commercial academic research, clinical practice, and educational applications. No licensing fees or per-administration royalties are required for researchers or healthcare practitioners utilizing the 33-item scale for clinical assessment or empirical investigation.
• Licensing and Reproduction Conditions: Users must maintain the integrity of the scale by citing the foundational validation papers (Toedter et al., 1988; Potvin et al., 1989; Toedter et al., 2001) in any resulting publications, clinical reports, or presentations. Modification of item stems, alteration of scoring formats, or integration into commercial digital platforms for profit requires formal permission from the copyright holders.

12. References

• Fernández-Sánchez, M. C., Pérez-Sánchez, J., & Cruz-Miranda, M. (2012). Psychometric properties of the Perinatal Grief Scale in a Spanish sample of bereaved mothers. Psicothema, 24(4), 629–635.
• Fischer, J., & Corcoran, K. J. (2007). Measures for clinical practice and research: A sourcebook (4th ed., Vol. 1, pp. 405–406). Oxford University Press. https://global.oup.com/academic/product/measures-for-clinical-practice-and-research-9780195300390
• Gawron, G., Krowatschek, C., & Brähler, E. (2015). Validierung der deutschen Version der Perinatal Grief Scale (PGS). Zeitschrift für Geburtshilfe und Neonatologie, 219(S 01), P118. https://doi.org/10.1055/s-0035-1566860
• Lasker, J. N., & Toedter, L. J. (1991). Acute versus chronic grief: The case of pregnancy loss. American Journal of Orthopsychiatry, 61(4), 510–522. https://doi.org/10.1037/h0079282
• Lasker, J. N., & Toedter, L. J. (2000). Predicting outcomes after pregnancy loss: Results from a longitudinal study. Illness, Crisis & Loss, 8(4), 350–372. https://doi.org/10.1177/105413730000800403
• Potvin, L., Lasker, J. N., & Toedter, L. J. (1989). Measuring grief: A short version of the Perinatal Grief Scale. Journal of Psychopathology and Behavioral Assessment, 11(1), 29–45. https://doi.org/10.1007/BF00962697
• Toedter, L. J., Lasker, J. N., & Alhadeff, J. M. (1988). The Perinatal Grief Scale: Development and initial validation. American Journal of Orthopsychiatry, 58(3), 435–449. https://doi.org/10.1111/j.1939-0025.1988.tb01604.x
• Toedter, L. J., Lasker, J. N., & Janssen, H. J. (2001). International comparison of studies using the Perinatal Grief Scale: A decade of research on pregnancy loss. Death Studies, 25(3), 205–228. https://doi.org/10.1080/074811801750073289

13. Items of the Scale