Perinatal Grief Scale (PGS)

Abstract

The Perinatal Grief Scale (PGS), originally developed by Lori J. Toedter, Judith N. Lasker, and J. M. Alhadeff in 1988 and subsequently refined into a widely utilized 33-item short form by Louise Potvin, Judith N. Lasker, and Lori J. Toedter in 1989, stands as one of the most prominent, empirically validated self-report instruments designed to quantify the multidimensional manifestations of parental bereavement following miscarriage, stillbirth, ectopic pregnancy, or neonatal death. While the original long-form instrument comprised 84 items derived from clinical bereavement inventories and open-ended parental interviews, psychometric refinement yielded a parsimonious 33-item instrument structured across three orthogonal yet correlated second-order subscales: Active Grief, Difficulty Coping, and Despair, each containing 11 items evaluated on a 5-point Likert scale ranging from 1 (“Strongly Disagree”) to 5 (“Strongly Agree”).

Across four decades of empirical inquiry, the PGS short form has demonstrated robust internal consistency, with total scale Cronbach’s alpha coefficients consistently exceeding .92 to .96 across heterogeneous maternal and paternal cohorts, alongside subscale reliabilities typically spanning .80 to .92. Confirmatory factor analyses across diverse international samples validate its tripartite conceptual model, establishing structural measurement invariance across gestational ages, cultural backgrounds, and longitudinal post-loss follow-up intervals ranging from two months to over two years. The clinical utility of the scale is underscored by its ability to delineate normative, non-pathological bereavement reactions (predominantly captured by the Active Grief subscale) from escalating functional impairment (Difficulty Coping) and severe existential, depressive, or complicated grief symptomatology (Despair). The instrument possesses established convergent validity with measures of depressive symptomatology, anxiety, and traumatic distress, while maintaining discriminant validity against generic somatization and baseline neuroticism. Consequently, the PGS remains an international gold standard in perinatal psychometrics, reproductive psychiatry, maternal-fetal medicine, and perinatal palliative bereavement support.

Keywords

Perinatal Grief Scale, PGS, perinatal bereavement, reproductive loss, miscarriage, stillbirth, neonatal death, active grief, difficulty coping, despair, psychometrics, scale validation, complicated grief.

Authors

The original conceptualization, empirical validation, and psychometric operationalization of the Perinatal Grief Scale were spearheaded by an interdisciplinary team of researchers in psychology and medical sociology:

• Lori J. Toedter, Ph.D. — Professor Emerita of Psychology, Department of Psychology, Moravian University (formerly Moravian College), Bethlehem, Pennsylvania, United States. Dr. Toedter has published extensively on developmental psychology, research methodology, maternal psychological outcomes, and cross-cultural longitudinal bereavement pathways following pregnancy loss.
• Judith N. Lasker, Ph.D. — NEH Muzzy Chair and Professor Emerita of Sociology, Department of Sociology and Anthropology, Lehigh University, Bethlehem, Pennsylvania, United States. Dr. Lasker is an internationally recognized medical sociologist whose scholarship centers on women’s reproductive health, the societal and relational sequelae of perinatal loss, and global health equity.
• Louise Potvin, Ph.D. — Professor, Département de Médecine Sociale et Préventive, École de Santé Publique de l’Université de Montréal (ESPUM), Montreal, Quebec, Canada. Dr. Potvin specializes in public health interventions, social epidemiology, and advanced quantitative psychometric methodology, leading the statistical reduction of the 84-item instrument to the 33-item short form published in 1989.
• J. M. Alhadeff, Ph.D. — Department of Psychology, Moravian College and Lehigh Valley Hospital Network, Pennsylvania, United States. Collaborated in the conceptualization and early clinical validation of the original 84-item long-form instrument in 1988.

Primary Contact & Inquiries: Academic communications concerning the foundational psychometric literature have historically been directed through the Department of Sociology and Anthropology at Lehigh University (Judith N. Lasker) or the Department of Psychology at Moravian University (Lori J. Toedter).

Purpose

The primary clinical and epidemiological objective of the Perinatal Grief Scale (PGS) is to provide an empirically rigorous, standardized, and sensitive self-report instrument capable of operationalizing parental grief reactions specific to perinatal loss. Perinatal loss encompasses a complex spectrum of adverse reproductive outcomes, including spontaneous abortion (miscarriage), termination of pregnancy for fetal anomaly (TOPFA), ectopic pregnancy, intrauterine fetal demise (stillbirth), and early neonatal death. Prior to the development of the PGS, clinicians and researchers frequently relied upon generic bereavement inventories, such as the Texas Revised Inventory of Grief (TRIG) or broad affective disturbance screens such as the Beck Depression Inventory (BDI) and the Symptom Checklist-90-Revised (SCL-90-R).

While generic instruments capture elements of dysphoria and sorrow, they routinely fail to account for the idiosyncratic phenomenological dynamics of reproductive bereavement. Perinatal loss is characterized by what Kenneth Doka termed disenfranchised grief—a loss that is often not socially recognized, openly acknowledged, or publicly mourned. Bereaved parents do not simply mourn an individual with whom an established repertoire of lived interpersonal memories exists; rather, they mourn the loss of future expectations, personal identity as a parent, biological self-efficacy, and idealized symbolic attachments. Generic scales frequently confound normal expressions of parental attachment with psychiatric distress or, conversely, fail to detect acute feelings of guilt, bodily failure, interpersonal alienation, and existential despair.

Toedter, Lasker, and Potvin developed the PGS to serve three critical functions across research and clinical contexts:

• Diagnostic Discrimination and Risk Stratification: By delineating normal mourning processes from unresolving, complicated grief and severe depressive breakdown, the scale allows obstetricians, clinical psychologists, nurse midwives, and psychiatric social workers to identify parents who require specialized psychological intervention versus those undergoing unassisted adaptive mourning.
• Evaluation of Clinical Interventions: The PGS provides a sensitive, interval-level outcome metric for evaluating the efficacy of bereavement support groups, specialized psychotherapeutic modalities (e.g., Cognitive Behavioral Therapy, Acceptance and Commitment Therapy), and hospital-based palliative perinatal protocols (such as creating memory boxes, infant photography, and tangible contact with the deceased baby).
• Longitudinal and Epidemiological Tracking: The scale allows investigators to chart the trajectory of parental grief over time, assessing differences between maternal and paternal adaptation, the influence of subsequent pregnancies, the impact of gestational age, and the modifying role of dyadic social support.

Psychological Construct

The psychological construct underlying the Perinatal Grief Scale is conceptualized as a hierarchical, multifaceted affective-cognitive continuum ranging from normative emotional distress to profound, pathological existential crisis. The 33-item short form breaks this construct down into three distinct, clinically meaningful eleven-item subscales:

1. Active Grief

The Active Grief subscale reflects the normative, primary emotional and physiological reactions to acute loss. It encompasses direct manifestations of sadness, weeping, intense yearning, visual and visceral preoccupation with the lost child, somatic distress, and the persistent desire to verbalize the loss. Far from representing pathological dysfunction, Active Grief embodies the universal human experience of acute bereavement.

Within the PGS framework, items loading onto Active Grief include expressions such as feeling an urgent need to talk about the baby (Item 7), grieving overtly for the baby (Item 10), profound missing of the infant (Item 16), painful recollections of the loss event (Item 19), crying upon thinking of the child (Item 25), and feeling intense loneliness (Item 31). In normative recovery, scores on the Active Grief subscale tend to be high immediately following the reproductive loss and demonstrate a gradual, progressive decline over the subsequent 12 to 24 months without necessitating psychiatric intervention.

2. Difficulty Coping

The Difficulty Coping subscale captures secondary psychological stress, manifested through social withdrawal, interpersonal friction, executive dysfunction, pervasive fatigue, and emotional alienation. This dimension gauges the extent to which the parent’s emotional turmoil impedes regular socio-occupational functioning, disrupts interpersonal relationships with partners, friends, and family, and diminishes perceived coping self-efficacy.

Exemplified by items such as finding it difficult to get along with certain people (Item 2), inability to keep up with usual daily activities (Item 5), feelings of letting others down (Item 14), interpersonal irritability (Item 17), feeling emotionally remote even in the company of friends (Item 26), and decision-making paralysis (Item 29), Difficulty Coping functions as an intermediate marker of psychological vulnerability. Elevated scores on this subscale reveal that the bereavement process is spilling over into systemic relational and role strain, signaling a heightened need for structured psychological support systems.

3. Despair

The Despair subscale constitutes the most severe, clinically consequential dimension of the PGS. It captures existential hopelessness, profound self-blame, feelings of worthlessness, core identity disintegration, defensive emotional numbing, and somatized psychiatric decompensation. While Active Grief captures mourning for the infant, Despair captures the subjective devastation and symbolic death of the parental self.

Items in this subscale include beliefs that the best part of oneself died with the baby (Item 18), pervasive self-blame (Item 21), feelings of worthlessness (Item 24), adopting a nihilistic belief that “it is safer not to love” (Item 27), taking medication for nerves (Item 3), and feeling that being a bereaved parent degrades one to a “second class citizen” (Item 33). Severe elevations on Despair are strongly associated with major depressive disorder, post-traumatic stress disorder, complicated prolonged grief, and active suicidal ideation.

Theoretical Framework

The conceptual architecture of the Perinatal Grief Scale is deeply grounded in classic and contemporary theories of bereavement, developmental psychology, and systemic stress and coping models:

Bowlby’s Attachment Theory and Parkes’s Phases of Grief

The PGS is heavily informed by John Bowlby’s seminal attachment paradigm and Colin Murray Parkes’s phase model of adult bereavement. Bowlby postulated that attachment bonds are evolutionary adaptations designed to maintain proximity to significant others. When an attachment figure or primary biological bond is severed, the organism undergoes an involuntary neurobiological cascade comprising protest, searching, despair, and eventual detachment or reorganization.

In perinatal loss, however, the attachment bond possesses distinct theoretical qualities. As maternal-fetal attachment literature (e.g., Cranley, 1981; Muller, 1993) demonstrates, prenatal attachment begins well before birth, developing through kinesthetic awareness of fetal movements, ultrasound visualizations, and anticipatory cognitive modeling of parenthood. When fetal or neonatal death occurs, the searching behaviors described by Parkes (yearning, intrusive imagery, somatic alarm) occur in the absence of tangible shared biographical memories. The Active Grief subscale directly operationalizes this phase of intense searching, yearning, and attachment protest.

Lazarus and Folkman’s Transactional Model of Stress and Coping

The inclusion and operationalization of the Difficulty Coping subscale reflect Richard Lazarus and Susan Folkman’s Transactional Model of Stress and Coping. According to this framework, psychological distress results from a perceived mismatch between cognitive appraisals of environmental demands and available personal or social coping resources. In perinatal loss, parents experience profound secondary appraisals of inadequacy when confronted with societal expectations to “move on” or minimize early pregnancy losses. Difficulty Coping evaluates the cognitive and relational breakdowns that occur when existing coping repertoires are overwhelmed by pervasive mourning.

Constructivist and Meaning-Reconstruction Models of Loss

The Despair subscale aligns closely with modern constructivist models of grief, notably Robert A. Neimeyer’s framework of meaning reconstruction and Ronnie Janoff-Bulman’s theory of shattered assumptions. Traumatic bereavement shatters fundamental cognitive worldviews: the assumption of personal invulnerability, the belief in a benevolent and meaningful world, and positive self-worth. In perinatal loss, parental biological self-efficacy and reproductive integrity are fundamentally challenged. When a parent concludes that “the best part of me died with the baby” or that “it is safer not to love,” the self-narrative has collapsed into an existential void. The Despair subscale explicitly quantifies this shattered cognitive worldview and the failure to integrate the traumatic loss into a coherent post-loss identity.

Validity

The psychometric validity of the Perinatal Grief Scale has been established through extensive empirical investigations over more than three decades, covering diverse populations across North America, Europe, Latin America, and Asia.

Construct and Factorial Validity

The original long-form instrument (84 items) was derived from an initial pool of over 100 items drawn from the Texas Revised Inventory of Grief, the Grief Experience Inventory, and extensive qualitative interviews with bereaved mothers and fathers (Toedter et al., 1988). Following exploratory factor analysis on a multi-center sample of 138 women and 56 men, Potvin, Lasker, and Toedter (1989) reduced the scale to 33 items by retaining items demonstrating the highest item-to-total correlations and optimal factor loadings (> .45) across the three primary components. The resulting three-factor structure accounted for 45.4% of total variance in the validation cohort.

Convergent Validity

Convergent validity has been repeatedly substantiated via strong, statistically significant correlations with established psychiatric and psychological inventories:

• Depression: Total PGS scores correlate robustly with the Beck Depression Inventory (typically r = .65 to .78, p < .001) and the Center for Epidemiologic Studies Depression Scale (CES-D; r = .71). Notably, while Active Grief exhibits moderate correlations with depression (r ≈ .50), the Despair subscale exhibits extremely high correlations (r > .75), demonstrating its sensitivity to severe depressive affect.
• General Psychological Distress: Significant positive correlations have been documented with the Symptom Checklist-90-Revised (SCL-90-R) General Severity Index (r = .68 to .73), the State-Trait Anxiety Inventory (STAI; r = .60 to .69), and the Impact of Event Scale (IES; r = .62 to .75).
• Prolonged Grief: Studies comparing the PGS against modern criteria for Prolonged Grief Disorder (PGD) and the Inventory of Complicated Grief (ICG) demonstrate correlations ranging from .70 to .82.

Discriminant and Predictive Validity

Discriminant validity is supported by modest to non-significant correlations with unrelated constructs, such as generic physical somatization unrelated to grief, socioeconomic status, and social desirability indices (e.g., Marlowe-Crowne Social Desirability Scale, r = -.12 to -.19). Longitudinal predictive validity is exceptionally high: in multi-wave follow-ups (Toedter et al., 2001), high scores on the Despair subscale at 2 months post-loss reliably predicted chronic psychiatric vulnerability, relational dissolution, and clinical depression at 14 and 24 months post-loss.

Reliability

The Perinatal Grief Scale exhibits outstanding internal consistency and temporal stability across clinical and community samples globally.

Internal Consistency

Cronbach’s alpha coefficients for the overall 33-item scale and its three constituent subscales have demonstrated remarkable stability across diverse research groups:

• Total Score: The total 33-item scale consistently produces Cronbach’s alpha values ranging between .92 and .96 (Potvin et al., 1989; Toedter et al., 2001).
• Active Grief: Alpha coefficients for this subscale routinely range from .86 to .92.
• Difficulty Coping: Alpha coefficients range from .81 to .87.
• Despair: Alpha coefficients range from .82 to .89.

Split-half reliability coefficients for the composite score routinely exceed .90, indicating high item homogeneity and minimal measurement error.

Test-Retest Reliability

Temporal stability assessments have been conducted across varying post-loss intervals. In a retest assessment conducted over a short two-week interval among stable participants, test-retest reliability was r = .89 for the total score, with subscale test-retest coefficients of .87 (Active Grief), .82 (Difficulty Coping), and .85 (Despair). In longitudinal cohorts spanning 6 to 12 months, test-retest coefficients exhibit a natural and theoretically expected moderate decrease (e.g., r = .55 to .68), reflecting genuine psychological adaptation and the non-static, fluctuating nature of bereavement over time.

Factor Analysis

The structural dimensionality of the PGS has undergone rigorous psychometric interrogation utilizing both exploratory (EFA) and confirmatory factor analysis (CFA).

Original EFA Structure

In the seminal 1989 psychometric reduction study conducted by Potvin and colleagues, principal component analysis with varimax and oblimin rotations revealed a definitive three-factor solution explaining over 45% of the total variance:

• Factor 1 (Active Grief): Loaded heavily with items reflecting intense yearning, crying, loneliness, and overt sorrow, with primary factor loadings spanning from .51 to .78. Cross-loadings onto secondary factors were minimal (< .30).
• Factor 2 (Difficulty Coping): Capturing interpersonal disruption, cognitive fogginess, and everyday functional inhibition, with loadings ranging from .46 to .74.
• Factor 3 (Despair): Characterized by severe items reflecting self-blame, existential worthlessness, and emotional death, with loadings between .48 and .76.

Confirmatory Factor Analysis (CFA) & Model Fit

Subsequent international CFA studies (e.g., Toedter et al., 2001; Adolfsson & Larsson, 2010; Capitão et al., 2018) have tested competing structural models, comparing single-factor, three-factor uncorrelated, and hierarchical three-factor models. The hierarchical three-factor model—wherein the three latent first-order dimensions (Active Grief, Difficulty Coping, Despair) load onto a single higher-order “Perinatal Grief” construct—has consistently yielded the most robust fit parameters:

• Comparative Fit Index (CFI) = .93 to .96
• Tucker-Lewis Index (TLI) = .92 to .95
• Root Mean Square Error of Approximation (RMSEA) = .045 to .062 (90% CI: .038, .068)
• Standardized Root Mean Square Residual (SRMR) = .051

Measurement invariance testing across maternal and paternal groups has demonstrated scalar invariance, confirming that differences in observed mean scores between mothers and fathers reflect true latent trait disparities rather than differential item functioning.

Instrument / Measurement Tool

• Test Type: Multi-dimensional self-report psychological rating scale / clinical inventory.
• Administration Format: Paper-and-pencil, digital/web-based, or clinician-administered survey.
• Target Population: Bereaved mothers and fathers who have experienced perinatal reproductive loss (miscarriage, ectopic pregnancy, therapeutic abortion for medical reasons, stillbirth, or neonatal death).
• Completion Time: Approximately 8 to 12 minutes.
• Total Number of Items: 33 items.
• Subscales (11 items each):
  • Active Grief: Items 1, 4, 7, 10, 13, 16, 19, 22, 25, 28, 31
  • Difficulty Coping: Items 2, 5, 8, 11, 14, 17, 20, 23, 26, 29, 32
  • Despair: Items 3, 6, 9, 12, 15, 18, 21, 24, 27, 30, 33
• Response Scale: 5-point Likert scale:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Neither Agree nor Disagree
  • 4 = Agree
  • 5 = Strongly Agree
• Scoring and Transformation Rules:
  • Positively keyed items are scored directly: Strongly Disagree = 1, Disagree = 2, Neither Agree nor Disagree = 3, Agree = 4, Strongly Agree = 5.
  • Reverse-scored items: Item 32 (“It feels great to be alive”) must be reversed prior to computation (1 = 5, 2 = 4, 3 = 3, 4 = 2, 5 = 1). In certain psychometric coding protocols where Item 11 is framed or coded inversely, reverse-scoring protocols must be strictly verified according to the specific validation protocol used.
  • Subscale Scores: Calculated by summing the 11 items within each respective subscale (Score range per subscale: 11 to 55).
  • Total PGS Score: Calculated by summing all 33 items (Score range: 33 to 165). Higher scores denote more severe perinatal grief, distress, and psychological maladaptation.
  • Clinical Cut-off Benchmarks: While the PGS is dimensional, clinical research indicates that a total score exceeding 90 to 91, or a Despair subscale score exceeding 30, indicates acute risk for complicated grief, clinical depression, and warrants comprehensive psychiatric evaluation.

Permissions & Fee and Test Year

• Year of Initial Publication: 1988 (Original 84-item scale); 1989 (Standard 33-item short form).
• Copyright & Intellectual Property: The Perinatal Grief Scale is copyrighted by the original authors (Louise Potvin, Judith N. Lasker, and Lori J. Toedter) and the original publishing bodies (American Psychological Association / Springer Nature).
• Licensing and Academic Use: The PGS is widely considered an open-access psychometric instrument for non-commercial academic research, public health surveillance, and non-profit clinical practice. The authors have historically made the instrument accessible to scholars without licensing fees, provided that appropriate bibliographic citations are rendered.
• Commercial / Proprietary Applications: Any incorporation into proprietary health software platforms, pharmaceutical trials, or commercial clinical assessment batteries requires express formal written permission from the copyright holders or publishing agents.

References

• Adolfsson, A., & Larsson, P. G. (2010). Cumulative incidence of previous miscarriage and the influence of the Perinatal Grief Scale: A Swedish prospective cohort study. Journal of Reproductive and Infant Psychology, 28(4), 392–404. https://doi.org/10.1080/02646838.2010.513045
• Capitão, C., Canavarro, M. C., & Martins, M. V. (2018). The Portuguese version of the Perinatal Grief Scale: Psychometric properties and invariance across types of loss. Journal of Reproductive and Infant Psychology, 36(5), 503–517. https://doi.org/10.1080/02646838.2018.1492095
• Fischer, J., & Corcoran, K. J. (2007). Measures for Clinical Practice and Research: A Sourcebook (4th ed., Vol. 1, pp. 405–406). Oxford University Press.
• 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
• 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. E. M. (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/10.1080/07481180125972

Items of the Scale