Published on in Vol 11, No 9 (2022): September

Preprints (earlier versions) of this paper are available at, first published .
The Impact of the COVID-19 Pandemic on Perinatal Loss Experienced by the Parental Couple: Protocol for a Mixed Methods Study

The Impact of the COVID-19 Pandemic on Perinatal Loss Experienced by the Parental Couple: Protocol for a Mixed Methods Study

The Impact of the COVID-19 Pandemic on Perinatal Loss Experienced by the Parental Couple: Protocol for a Mixed Methods Study


1Observatory of Perinatal Clinical Psychology, Department of Clinical and Experimental Science, University of Brescia, Brescia, Italy

2Department of Philosophy, Sociology, Education and Applied Psychology, University of Padova, Padova, Italy

3IT and Statistical Services, Multifunctional Centre of Psychology, University of Padova, Padova, Italy

Corresponding Author:

Loredana Cena, Prof Dr, PsyD

Observatory of Perinatal Clinical Psychology

Department of Clinical and Experimental Science

University of Brescia

Viale Europa 11

Brescia, 25123


Phone: 39 0303717274


Background: At the beginning of 2020, mothers and fathers who experienced perinatal events (from conception to pregnancy and postpartum period) found themselves facing problems related to the emergency caused by the COVID-19 pandemic and the associated difficulties for health care centers in providing care. In the unexpected and negative event of perinatal loss (ie, miscarriage, stillbirth, and neonatal death) more complications occurred. Perinatal loss is a painful and traumatic life experience that causes grief and can cause affective disorders in the parental couple—the baby dies and the couple’s plans for a family are abruptly interrupted. During the COVID-19 pandemic, limited access to perinatal bereavement care, due to the lockdown measures imposed on medical health care centers and the social distancing rules to prevent contagion, was an additional risk factor for parental mental health, such as facing a prolonged and complicated grief.

Objective: The main aims of this study are as follows: to investigate the impact of COVID-19 on mothers and fathers who experienced perinatal loss during the pandemic, comparing their perceptions; to evaluate their change over time between the first survey administration after bereavement and the second survey after 6 months; to examine the correlations between bereavement and anxiety, depression, couple satisfaction, spirituality, and sociodemographic variables; to investigate which psychosocial factors may negatively affect the mourning process; and to identify the potential predictors of the development of complicated grief.

Methods: This longitudinal observational multicenter study is structured according to a mixed methods design, with a quantitative and qualitative section. It will include a sample of parents (mothers and fathers) who experienced perinatal loss during the COVID-19 pandemic from March 2020. There are two phases—a baseline and a follow-up after 6 months.

Results: This protocol was approved by the Ethics Committee of Psychological Research, University of Padova, and by the Institutional Ethics Board of the Spedali Civili of Brescia, Italy. We expect to collect data from 34 or more couples, as determined by our sample size calculation.

Conclusions: This study will contribute to the understanding of the psychological processes related to perinatal loss and bereavement care during the COVID-19 pandemic. It will provide information useful to prevent the risk of complicated grief and psychopathologies among bereaved parents and to promote perinatal mental health.

International Registered Report Identifier (IRRID): DERR1-10.2196/38866

JMIR Res Protoc 2022;11(9):e38866



Background and Rationale

The COVID-19 pandemic has seen almost 500 million people infected with the disease, including more than 6 million deaths globally [1]; it has also caused a global health, social, and economic crisis, with negative effects on the general population. Lockdown measures imposed to curb the spread of the infection [2] led to physical and emotional isolation, and this resulted in a global situation of uncertainty and psychological distress [3-5].

The COVID-19 pandemic also had collateral effects on mental health [6,7], with an increase in mental disorders in the general population [8] and mainly affecting the most vulnerable [9]. There are indeed indications that the adverse effects of health and social disasters are greater among vulnerable groups, such as the perinatal population [10]. The perinatal population is particularly vulnerable [11-13]—the period from conception to pregnancy and postpartum, which involves physiological, psychological, and social changes [14-16] and presents complex challenges for women [17] and men [18] who “transition to parenthood” [19]. Screenings over the prenatal and postnatal period [20] demonstrate that parents (mothers and fathers) may experience affective disorders [21] such as anxiety [22,23] and depression [24,25], also with comorbidity [26], with the risk of negative consequences for the mother’s health (eg, risks of miscarriage, pre-eclampsia, and gestational hypertension), and negative effects on the child’s development (premature birth; lower appearance, pulse, grimace, activity, and respiration scores; and low birth weight) [27] and on parents-infant relationships [28-30].

Due to the COVID-19 pandemic, these risk factors increased in the perinatal period; there were interruptions to the provision of perinatal health care services and changes to their structure [31,32]. During pregnancy, checkups and many routine outpatient visits were canceled [33,34], and there was a reduction in obstetric and psychological follow-ups. Delivery procedures during the pandemic also changed [35], with fathers not allowed to assist during labor. Lockdown and social isolation, together with restricted visits to maternity wards during hospitalization, in an effort to limit the risk of transmission of the virus, which reduced contact with family members, increased the negative psychological impact on the mother due to the lack of perceived social support [36,37]. Social support from the partner was also affected [38,39], as fathers were almost always not allowed to accompany mothers for checkups in health care centers. Preterm newborns were isolated from their mothers and fathers in the neonatal intensive care unit [40]. The pandemic restrictions also affected the immediate postpartum period, with interruptions in early dyadic relationships, particularly in mother-infant attachment [41]. International literature on COVID-19 effects reports mental health implications and distress in women during pregnancy [42], delivery, and postpartum [38,43], with an increasing prevalence of perinatal depression, anxiety [44-46], and posttraumatic stress disorders [47]. Pregnant mothers’ anxiety of attending checkups in clinics during routine prenatal care, due to the fear of being infected by SARS-CoV-2, and uncertainty about the effect of the virus on the fetus and infant, led to the postponing or cancelling of routine medical health care appointments [48], even though there was no consistent evidence of potential vertical intrauterine transmission of COVID-19 from mother to fetus [49,50]. The data collected by international researchers are controversial due to the lack of knowledge about the virus, which has generated many uncertainties about its long-term effects.

During the pandemic health emergency, maternal and fetal outcomes worsened globally, although there are limited data indicating that SARS-CoV-2 infection caused higher levels of adverse perinatal outcomes [51,52], measured in infected pregnant women compared to noninfected pregnant women [53]. Adverse outcomes include increased risks of perinatal loss [54,55]. Perinatal loss, that is, miscarriage (>20 weeks), stillbirth (>20 weeks gestation), or neonatal death (newborn in the first 28 days of life) [56], is an unexpected and complex negative life event, an experience that has always been poorly investigated. If we consider the period prior to the COVID-19 pandemic, more than 2 million perinatal deaths (stillbirths) and 2.9 million neonatal deaths occur worldwide every year [57]. However, The Lancet reports that not all of these deaths are recorded [58], and in the countries where the highest mortality occurs, the cause of these deaths is often not even identified. It should be noted that this high incidence has an economic impact on both global health and social systems [59]. Only recently did the World Health Organization [60] issue an operational guide to Maternal and Perinatal Death Surveillance and Response.

Perinatal death causes grief for the parental couple, requiring bereavement care [61]. In the international literature, “perinatal loss” refers to the death of the child in the perinatal period, but the term “loss” does not describe the parents’ state of mind and the complex psychological aspects of their suffering caused by this death. Perinatal loss is a painful and traumatic experience that can negatively affect a couple’s life; when the child dies, the plans for a new arrival in the family are abruptly halted, and the couple must process their mourning [62-65]. This interior processing of the grief over death is a necessary event, and the extent of their suffering depends on the affective investment of the parental couple in the child [66-69].

The possible negative consequences in terms of parental health can include affective disorders, such as anxiety, depressive, psychosomatic, and posttraumatic stress disorders [70]. Bereavement can lead to a crisis of faith [71], and the literature confirms that this can also occur in perinatal loss [72,73]. Perinatal loss is a biologically negative event, a particularly inexplicable experience; in the order of life events, children outlive their parents, hence the suffering of bereaved parents. Spirituality can serve as a coping mechanism to soften the complex painful feelings by helping mourners adapt to loss, and spiritual practices have been associated with better adjustment after the death of a child [71]. In a recent Italian study involving women who have experienced perinatal loss, it was found that religion helps them to accept grief and give meaning to such a tragedy [61].

There is a strong emotional impact also on the health care professionals working in maternity units [72,74]. It is important that these professionals understand parental perceptions to prevent the onset of psychopathologies, as perinatal mortality is an experience in which the early activation of the grief process is exacerbated by the circumstances surrounding this event [75].

During the pandemic period, mothers and fathers who suffered a perinatal loss found themselves experiencing further problems relating to COVID-19 [76], with the associated difficulties of the health system. Inpatient care for perinatal loss consists of bereavement care [77] according to specific clinical guidelines [78,79], which health care professionals were unable to follow during the pandemic to support parents. COVID-19 restrictions affected the provision of bereavement care compared to the period before the pandemic [80]. Personal protective equipment also prevented expressions of empathy from the operators, and support by means of physical contact was no longer permitted. There was also no time to train health workers adequately so that they could deal with the changes appropriately. These changes in care caused resentment among parents [81] and raised concerns over the possible negative impact on the long-term mourning process for parents and families [82] and increased risk of complicated grief [83].

The University of Padova and the University of Brescia propose a multicenter study, based in Italy, to optimize scientific knowledge in the field of studies of the effects of the COVID-19 pandemic on the perinatal period. There is a paucity of studies evaluating the psychological impact of the COVID-19 pandemic on couples experiencing the loss of their child in the perinatal period.


The main aims of this study are as follows:

  • To investigate the impact of COVID-19 on mothers and fathers who experienced perinatal loss during the COVID-19 pandemic, comparing mothers’ and fathers’ perceptions
  • To evaluate the change over time for fathers and mothers between the first survey after bereavement and the second survey, after 6 months
  • To examine correlations of bereavement with anxiety, depression, couple satisfaction, spirituality, and sociodemographic variables. The main hypothesis is that the trauma was severe, to a greater extent for mothers, with outcomes of anxiety and depression. It is also hypothesized that more negative outcomes are related to difficult relationships, and this combination of traumatic experiences can lead to a crisis of faith, thus reducing the chances of resorting to religion as a coping mechanism
  • To investigate which psychosocial factors negatively affect the mourning process, and identify the potential predictors of the development of complicated grief

Study Design

This longitudinal observational multicenter study is structured according to a mixed methods design, with a quantitative and qualitative part. The timeline of the whole procedure is shown in Figure 1. The study comprises two phases, which are a baseline (Figure 1: T1) and a 6-month follow-up (Figure 1: T2).

Figure 1. Timeline.
View this figure


Health care professionals (psychologists, psychotherapists, psychiatrists, midwives, etc) will conduct the study at health care centers throughout Italy (counseling centers, hospitals, etc) and the facilities involved and coordinated by the Observatory of Perinatal Clinical Psychology of the University of Brescia (Table 1). Among the mothers and fathers attending the health care centers, health care professionals will identify those who have experienced perinatal loss since the beginning of the COVID-19 pandemic (from March 2020) and will inform them about the study (Figure 1: T0). Health care professionals will provide mothers and fathers with an information note describing the aims of the study and will ask them to sign a declaration of informed consent if they intend to participate in the study. The first data collection time point (Figure 1: T1) will be after the death of the child, as soon as the parental couples are available to participate in the study, considering the difficulties due to the trauma for their perinatal loss. To protect their privacy, parents who agree to participate will be assigned a code with which they will become part of the study (participants can authorize the communication of their name to the research centers). Health care professionals will communicate the code or name of individuals participating to the Observatory of Perinatal Clinical Psychology of the University of Brescia. Both health care professionals and recruited participants will take part in this study voluntarily and without compensation.

Table 1. Health care professionals and health care centers, as well as facilities involved and coordinated by the Observatory of Perinatal Clinical Psychology of the University of Brescia.
LocationUnit type and nameHealth care professionals
  • ASSTa Bergamo Est; Obstetrics OUb
  • 1 PsyDc
  • ASST Spedali Civili Hospital; Clinic and Family Centers
  • 1 PsyD
  • 2 Psychologists
  • 2 Midwives
  • Specialist Clinic of Perinatal Psychology
  • 2 PsyDs
  • Umberto I Hospital; Obstetrics and Gynecology OUCd
  • 1 PsyD
  • LHAe of Toscana Centro; Family Clinic
  • 2 PsyDs
  • ASST Lodi; Obstetrics OU
  • 1 Midwife
  • ASST Mantua Carlo Poma Hospital; Maternal and Child Department
  • Clinical Psychology; Obstetrics and Gynecology OUC and NICUf
  • 2 PsyDs
  • Arcobaleno and Pep Nursery School
  • 1 Educationalist
  • Kairos Donna Association
  • 1 Psychologist
  • Buccheri La Ferla Hospital and Georgia Association
  • 1 PsyD
  • LHA 3 of Turin; Specialist Centers of Perinatal Psychology
  • 1 PsyD
  • Specialist Clinic of Perinatal Psychology
  • 1 PsyD
  • ULSS8 Berica; Mental Health Department
  • 1 Psychiatrist

aASST: Azienda Socio Sanitaria Territoriale.

bOU: unit or department.

cPsyD: psychologist-psychotherapist.

dOUC: operating unit complex.

eLHA: local health authority.

fNICU: neonatal intensive care unit.

Eligibility Criteria

Mothers and fathers who experienced perinatal loss during the COVID-19 pandemic form March 2020 and who are proficient in Italian are included in the study.

The main exclusion criterion is mental health—participants must not be diagnosed with a mental disorder by a psychiatrist and must not be undergoing psychiatric or psychopharmacological treatment.

Materials and Procedure

In this Study, the participants (mothers and fathers) will be invited to participate in two phases of data collection. In the first phase (Figure 1: baseline—T1) they will perform the following:

  • Complete a questionnaire (quantitative instrument) by the University of Brescia, which will be administered by the health professionals. The responses to the questionnaire will be entered by the health professionals directly into a web-based survey. Researchers at the University of Brescia will verify the quality of the data and coordinate the network of health professionals.
  • Sit an interview (qualitative instrument) administered by specialized and trained researchers from the University of Padova, for consistency. The interview will be analyzed using thematic analysis [84].

In the second phase of data collection (Figure 1: follow-up—T2, after 6 months), mothers and fathers will be asked to complete the questionnaire and the interview by health care professionals. All data collected at each step will be deidentified and stored in a secure, password-protected drive with access only available to the research team members.

Study Outcomes

The primary outcome for this study is the impact of the COVID-19 pandemic on the grief of mothers and fathers who experienced a perinatal loss during the pandemic. The secondary outcomes are the changes in social and couple relationships, maternal or paternal affectivity and satisfaction, spirituality, trauma, grieving strategies, and unhelpful or helpful factors. The tertiary outcomes relate to understanding the type of responsibility that parents ascribe to COVID-19 with respect to their perinatal loss.

Quantitative Measurement (Survey)
Sociodemographic Assessment Form for Mother or Father

The Sociodemographic Assessment Form has been designed to collect the mother’s or father’s sociodemographic data (ie, age, nationality, academic qualifications, professional status, economic situation, and current marital status) and anamnestic data (ie, date of birth; week of gestational age of the baby at the time of delivery; health facility where the birth took place; number of pregnancies; possible abortions; any mental disorders diagnosed; psychological therapies in progress; medication taken for depression, anxiety, or other problems; and perceived social support, eg, from family, friends, health services).

COVID-19—the Impact of Event Scale-Revised

The Impact of Event Scale-Revised [85] is a 22-item self-report tool that assesses subjective distress caused by traumatic events. Respondents are asked to identify a specific stressful life event and then indicate the degree of distress they felt over the following 7 days by each “difficulty” listed. Items are rated on a 5-point scale ranging from 0 (“not at all”) to 4 (“extremely”). The Impact of Event Scale-Revised yields a total score (ranging from 0 to 88), and subscale scores can be calculated for the Intrusion, Avoidance, and Hyperarousal subscales.

Prolonged Grief-13

The Prolonged Grief-13 [86] is a self-administered questionnaire consisting of 13 items, which evaluates the diagnosis of prolonged bereavement. The result is calculated based on an algorithm consisting of the following five criteria: (1) event of the loss; (2) separation distress (items 1-2); (3) duration (item 3); (4) cognitive, emotional, and behavioral symptoms (items 4-12); and (5) significant functional impairment, 6 months after loss (item 13). All five criteria must be met to diagnose prolonged grief disorder. The total score on the prolonged grief symptom scale is obtained by summing criteria (2) and (4).

Perinatal Assessment of Paternal or Maternal Affectivity

The Perinatal Assessment of Paternal or Maternal Affectivity [21] is a 10-item self-report questionnaire that investigates the following 8 dimensions: anxiety, depression, perceived stress, irritability or anger, relationship problems (eg, in couple, family, with friends, and at work), behavioral alterations of illness (eg, somatization, functional medical syndromes, and hypochondriac complaints), physiological disorders (eg, sleep, appetite, or sexual desire disorders), addictive disorders, and behavioral acting out. Some questions related to the paternity or maternity experience and the possible influence of sociocultural factors are included. The responses are indicated with an X on an analog line, with a rating from “Not at all” to “Very.” The line has small points, each of which corresponds to a score from 0 to 10. The tool allows us to identify fathers or mothers who have a significant risk of manifesting perinatal affective disorders. It is very simple to administer and quick to fill in, is suitable for different contexts, and is usable by professionals with different skills, both in public and private care settings.

Dyadic Adjustment Scale Brief Version

The Dyadic Adjustment Scale brief version [87] is a shortened version of the Dyadic Adjustment Scale. It is a self-report tool for evaluating couple satisfaction and is composed of the following 4 items: three items are on a 6-point Likert scale, ranging from 0 (all the time) to 5 (never), while the final item is on a 7-point scale ranging from 0 (extremely unhappy) to 6 (perfect).

Daily Spiritual Experiences Scale

The Daily Spiritual Experiences Scale [88] is a self-report tool composed of 16 items with 6-point Likert response (1=never; 6=many times), and it examines the dimension of the perception of the transcendent in the individual and their perception of interaction with the transcendent in daily life.

Inventory of Complicated Spiritual Grief

The Inventory of Complicated Spiritual Grief [89] measures how much individuals specifically consider the level of loss experienced when responding to indicators of spiritual crisis that affect their relationship both with God and with fellow worshipers. It is composed of 18 items (Annex 5) with a 5-point Likert response scale (0=not true at all and 4=absolutely true). The factorial analysis highlighted a 2-factor structure, as follows: (1) “Insecurity with God,” which is composed of 7 items that investigate the individual’s insecurity toward their relationship with God, and (2) “Disruption in Religious Practice,” which is composed of 11 items that investigate how far the individual has abandoned religious practices.

Qualitative Measurement (Interview)
Thematic Analysis

Thematic analysis [84] has been widely used in mixed methods design, because it can be applied to a broad range of epistemologies and research questions, enabling researchers who use different research methods to communicate with each other [90]. It is a method for identifying, analyzing, organizing, describing, and reporting themes identified within a qualitative data set [84], producing trustworthy and insightful findings [91].

Sample Size Estimation

The primary endpoint of this study is the impact of the COVID-19 pandemic on the grief of mothers and fathers who experienced a perinatal loss during the pandemic. Considering a power (1-β) of 0.80 and a type I error (α) of .05, a sample of 34 parental couples is needed. The sample size is extremely low, but it will be in line with literature studies on perinatal loss that include and analyze small samples of couples [92,93]. As indicated by literature [94], the mixed methods design can help studies that involve small samples.


Quantitative and qualitative analysis will be carried out for the questionnaires and interviews. Appropriate data analysis will be performed using standard statistical packages.

Quantitative Data Analysis

The following steps will be performed: (1) descriptive analysis of all questionnaires prepared for the mother and father and evaluation of the differences between mother and father using 2-tailed t test for matched pairs. The results of the power analysis conducted using the GPower program indicate that comparison of the averages for fathers and mothers assuming an average effect, an alpha level of .05, and a power of .80 requires at least 34 couples; (2) evaluation of the change over time for mother and father between the first survey (after bereavement) and second survey (after 6 months) using repeated measured ANOVA. The results of the power analysis conducted using the GPower program indicate that comparison of the averages over time (2 measurements over time), for fathers and mothers assuming an average effect, an alpha level of .05, and a power of .80 requires at least 34 couples; (3) preliminary examination of the bivariate correlations between the measurements examined in the study and the sociodemographic variables using Pearson correlation; and (4) define a multiple regression model with the main predictive variables of the management of perinatal bereavement (including only the variables found to be significant in the preliminary examination). The results of the power analysis conducted using the GPower program indicate that a multiple regression model capable of explaining a significant share of the variability of the scores of the dependent variable, assuming a medium-sized effect, an alpha level of .05, and a power of .80, requires at least 92 people, including 5 predictors in the model, and at least 118 people, including 10 predictors in the model. Finally, if we manage to reach the number of 100 participants, estimating between 10% and 15% attrition, we will be able to proceed as described.

Qualitative Data Analysis

Participants (ie, the father and mother) will be asked to sit a semistructured interview that will further explore the issues investigated by the questionnaires. Parent interviews will be carried out separately via the Zoom platform. The interviews will be fully recorded and transcribed verbatim to be analyzed with the support of the Atlas.ti software. A thematic analysis will be carried out on the transcripts to identify the main common themes among the interviewees. We will focus on recognizable convergences and specificities through an appropriate comparison of the texts. The emerging themes identified within the experiences narrated by the participants will allow researchers to create a shared codebook within which the sentences stated by the participants will be assigned to a category according to the identified theme. The analysis will follow the 6 basic phases of preparation, generation of categories or themes, data encoding, verification of emerging understanding, search for alternative explanations, and drafting of the report. To verify the accuracy of the analysis and the interpretative procedures adopted by the interviewer and the supervisor, 2 other members of the research team will work on the texts until an agreement is reached between all researchers. The Atlas.ti software will be used to facilitate the identification of themes and will facilitate the creation of network graphics to describe the logical relationships between the concepts and categories identified by the researchers.

Ethics Approval

Our study protocol was reviewed and approved by the Ethics Committee of Psychological Research, University of Padova (N. 3989 - 09/02/2021), and by the Institutional Ethics Board of the Spedali Civili of Brescia, Italy (N. NP4858 - 07/10/2021). All procedures performed in this study are in accordance with the ethical standards of the Institutional Ethics Board of the Spedali Civili of Brescia, and with the Declaration of Helsinki 1964 and subsequent amendments. We shall obtain written consent from the parents.

Patient and Public Involvement

The parents were not involved in the design, conduct, reporting, or dissemination plans of this research.

Confidentiality Procedure and Access to Data

Personal information about potential and enrolled participants will be collected only by members of the research team and cannot be accessed by other individuals. Personal information and survey data will be pseudonymized using an identification number. Only authorized study personnel will have access to any of the data associated with this study.

According to our sample size calculation, we expect that at least 34 couples from health care centers located in Italy will participate in the study.

We will publish all results in peer-reviewed international journals indexed in Web of Science or Scopus databases and present them at national and international conferences.


The COVID-19 pandemic forced health services to redefine perinatal bereavement care protocols [78,79] due to the restrictions imposed to curb the spread of the virus. However, health care professionals were unprepared for these changes [31,32], which led to an increase in perinatal affective disorders in mothers and fathers [70], who felt isolated and lacking social support [36,37] at such a challenging time. To our knowledge, the impact of COVID-19 on care following the death of a baby has not been sufficiently explored.

This multicenter study will contribute to optimize the scientific knowledge in the field of studies of the impact of the COVID-19 pandemic on pregnancy and particularly on mothers and fathers grieving for a perinatal loss. It will contribute to the understanding of the psychological processes related to perinatal loss, bereavement care, and mourning during the COVID-19 pandemic; it will also provide information useful to preventing the risk of prolonged and complicated grief and parent psychopathologies and will promote perinatal mental health.

Regarding the implications in clinical practice, it would seem important to implement psychological services in health care centers (eg, counseling centers and obstetrics and gynecology wards) that can offer adequate support to mothers, fathers, and families who are experiencing the unexpected and painful event of perinatal loss of their child, especially if this happens in difficult and complex situations such as a global health emergency.

This study could pave the way for future scientific research in the same or similar area of interest that should consider perinatal bereavement, an event still poorly investigated and not always socially recognized, to develop a strong support system for the affected mothers, fathers, and families.


The most likely limitation of this study could be that some parents contacted by health care professionals may not agree to participate because the perinatal loss event may have been too traumatic and painful, and they may not want to talk about it anymore after it happened. Concerning data collection time point, recruited parental couples may not have experienced perinatal loss in the same week of pregnancy or in the same neonatal period, and this could be another limitation of this study. What the sample couples share is that the perinatal loss event occurred during the COVID-19 pandemic. Lastly, the sample, composed only of parents who speak and understand the Italian language, may be too small to be able to generalize the results.


We thank all the mothers and fathers who will take part in the study and the health care professionals who will apply the study on the Italian territory at health care centers and the following facilities involved and coordinated by the Observatory of Perinatal Clinical Psychology of the University of Brescia: Lucia Bonassi (Azienda Socio Sanitaria Territoriale [ASST] Bergamo Est), Andrea Benlodi and Sara Petterlini (ASST Mantua Carlo Poma Hospital), Adriana Testa, Luigia Soldati, Fernanda Maturilli, Anna Zucchetti and Laura Cabini (ASST Spedali Civili Hospital Brescia), Alessandra Gianni and Anna Amati (Specialist Clinic of Perinatal Psychology, Como), Maria Pistillo (Umberto I Hospital, Enna), Isabella Lapi and Barbara Santoni (Local Health Authority [LHA] of Toscana Centro, Florence), Giovanna De Gregorio (Arcobaleno and Pep Nursery School, Lecco), Ilda di Claudio (ASST Lodi), Barbara Ferrari (Kairos Donna Association, Padua), Loredana Antonia Messina (Buccheri La Ferla Hospital and Georgia Association, Palermo), Sonia Scarponi (LHA 3 of Turin), Arianna Donolato (Specialist Clinic of Perinatal Psychology, Venice), and Rossana Riolo (ULSS8 Berica, Vicenza).

This work was funded by the Observatory of Perinatal Clinical Psychology—Department of Clinical and Experimental Sciences of the University of Brescia, Italy.

Data Availability

Data sharing does not apply to this article as data sets will not be generated or analyzed in this article.

Authors' Contributions

IT and LC contributed equally to the general study design. LC and AT coordinate and manage the implementation of the study at each health care center. AT verifies the quality of the quantitative data. EI administers the interviews and processes the qualitative data. IT conceptualized the study, the statistical plan, and qualitative analysis. LR conducts the statistical analysis. LC and AT drafted the first version of the manuscript. IT revised the draft of the manuscript. All authors have read and approved the final manuscript.

Conflicts of Interest

None declared.

  1. WHO coronavirus (COVID-19) dashboard. World Health Organization.   URL: [accessed 2022-04-07]
  2. Ebrahim SH, Ahmed QA, Gozzer E, Schlagenhauf P, Memish ZA. Covid-19 and community mitigation strategies in a pandemic. BMJ 2020 Mar 17;368:m1066. [CrossRef] [Medline]
  3. Cavicchioli M, Ferrucci R, Guidetti M, Canevini MP, Pravettoni G, Galli F. What Will Be the Impact of the Covid-19 Quarantine on Psychological Distress? Considerations Based on a Systematic Review of Pandemic Outbreaks. Healthcare (Basel) 2021 Jan 19;9(1):101 [FREE Full text] [CrossRef] [Medline]
  4. Reizer A, Geffen L, Koslowsky M. Life under the COVID-19 lockdown: On the relationship between intolerance of uncertainty and psychological distress. Psychol Trauma 2021 May;13(4):432-437. [CrossRef] [Medline]
  5. Rettie H, Daniels J. Coping and tolerance of uncertainty: Predictors and mediators of mental health during the COVID-19 pandemic. Am Psychol 2021 Apr;76(3):427-437. [CrossRef] [Medline]
  6. Bottemanne H, Delaigue F, Lemogne C. SARS-CoV-2 Psychiatric Sequelae: An Urgent Need of Prevention. Front Psychiatry 2021 Sep 9;12:738696 [FREE Full text] [CrossRef] [Medline]
  7. Stefana A, Youngstrom EA, Chen J, Hinshaw S, Maxwell V, Michalak E, et al. The COVID-19 pandemic is a crisis and opportunity for bipolar disorder. Bipolar Disord 2020 Sep 04;22(6):641-643 [FREE Full text] [CrossRef] [Medline]
  8. Pierce M, Hope H, Ford T, Hatch S, Hotopf M, John A, et al. Mental health before and during the COVID-19 pandemic: a longitudinal probability sample survey of the UK population. The Lancet Psychiatry 2020 Oct;7(10):883-892. [CrossRef]
  9. Stefana A, Youngstrom EA, Hopwood CJ, Dakanalis A. The COVID-19 pandemic brings a second wave of social isolation and disrupted services. Eur Arch Psychiatry Clin Neurosci 2020 Sep 15;270(6):785-786 [FREE Full text] [CrossRef] [Medline]
  10. Harville E, Xiong X, Buekens P. Disasters and perinatal health:a systematic review. Obstet Gynecol Surv 2010 Nov;65(11):713-728 [FREE Full text] [CrossRef] [Medline]
  11. Iyengar U, Jaiprakash B, Haitsuka H, Kim S. One Year Into the Pandemic: A Systematic Review of Perinatal Mental Health Outcomes During COVID-19. Front Psychiatry 2021 Jun 24;12:674194 [FREE Full text] [CrossRef] [Medline]
  12. Ahmad M, Vismara L. The Psychological Impact of COVID-19 Pandemic on Women's Mental Health during Pregnancy: A Rapid Evidence Review. Int J Environ Res Public Health 2021 Jul 02;18(13):7112 [FREE Full text] [CrossRef] [Medline]
  13. Cataudella S, Congiu N, Langiu G. L'impatto psicologico della pandemia da Covid-19 sul periodo perinatale: una breve review dei primi dati della letteratura sul contesto italiano ed internazionale. Psicologia della Salute 2022:15-38. [CrossRef]
  14. Howard LM, Khalifeh H. Perinatal mental health: a review of progress and challenges. World Psychiatry 2020 Oct;19(3):313-327 [FREE Full text] [CrossRef] [Medline]
  15. Imbasciati A, Cena L. Il futuro dei primi mille giorni di vita. Psicologia Clinica Perinatale: prevenzione e interventi precoci. Milan, Italy: Franco Angeli; 2018.
  16. Imbasciati A, Cena L. Psicologia Clinica Perinatale Babycentered. Come si costruisce la mente umana. Milan, Italy: Franco Angeli; 2020.
  17. McCarthy M, Houghton C, Matvienko-Sikar K. Women's experiences and perceptions of anxiety and stress during the perinatal period: a systematic review and qualitative evidence synthesis. BMC Pregnancy Childbirth 2021 Dec 06;21(1):811 [FREE Full text] [CrossRef] [Medline]
  18. Shorey S, Chan V. Paternal mental health during the perinatal period: A qualitative systematic review. J Adv Nurs 2020 Jun 25;76(6):1307-1319. [CrossRef] [Medline]
  19. Parfitt Y, Ayers S. Transition to parenthood and mental health in first-time parents. Infant Ment Health J 2014 Mar 31;35(3):263-273. [CrossRef] [Medline]
  20. Cena L, Palumbo G, Mirabella F, Gigantesco A, Stefana A, Trainini A, et al. Perspectives on Early Screening and Prompt Intervention to Identify and Treat Maternal Perinatal Mental Health. Protocol for a Prospective Multicenter Study in Italy. Front Psychol 2020 Mar 11;11:365 [FREE Full text] [CrossRef] [Medline]
  21. Baldoni F, Matthey S, Agostini F, Schimmenti A, Caretti V. Perinatal Assessment of Paternal Affectivity (PAPA). First validation in Italian samples. Infant Mental Health Journal 2018:311.
  22. Dennis CL, Falah-Hassani K, Shiri R. Prevalence of antenatal and postnatal anxiety: systematic review and meta-analysis. Br J Psychiatry 2017 May 25;210(5):315-323 [FREE Full text] [CrossRef] [Medline]
  23. Cena L, Mirabella F, Palumbo G, Gigantesco A, Trainini A, Stefana A. Prevalence of maternal antenatal anxiety and its association with demographic and socioeconomic factors: A multicentre study in Italy. Eur Psychiatry 2020 Sep 07;63(1):e84 [FREE Full text] [CrossRef] [Medline]
  24. Grigoriadis S, VonderPorten EH, Mamisashvili L, Tomlinson G, Dennis C, Koren G, et al. The Impact of Maternal Depression During Pregnancy on Perinatal Outcomes. J Clin Psychiatry 2013 Apr 15;74(04):e321-e341. [CrossRef]
  25. Cena L, Mirabella F, Palumbo G, Gigantesco A, Trainini A, Stefana A. Prevalence of maternal antenatal and postnatal depression and their association with sociodemographic and socioeconomic factors: A multicentre study in Italy. J Affect Disord 2021 Jan 15;279:217-221 [FREE Full text] [CrossRef] [Medline]
  26. Cena L, Gigantesco A, Mirabella F, Palumbo G, Camoni L, Trainini A, et al. Prevalence of comorbid anxiety and depressive symptomatology in the third trimester of pregnancy: Analysing its association with sociodemographic, obstetric, and mental health features. J Affect Disord 2021 Dec 01;295:1398-1406 [FREE Full text] [CrossRef] [Medline]
  27. Zhang S, Ding Z, Liu H, Chen Z, Wu J, Zhang Y, et al. Association between mental stress and gestational hypertension/preeclampsia: a meta-analysis. Obstet Gynecol Surv 2013;68(12):825-834. [CrossRef]
  28. Tambelli R, Cimino S, Cerniglia L, Ballarotto G. Early maternal relational traumatic experiences and psychopathological symptoms: a longitudinal study on mother-infant and father-infant interactions. Sci Rep 2015 Sep 10;5(1):13984 [FREE Full text] [CrossRef] [Medline]
  29. Riva Crugnola C, Ierardi E, Ferro V, Gallucci M, Parodi C, Astengo M. Mother-Infant Emotion Regulation at Three Months: The Role of Maternal Anxiety, Depression and Parenting Stress. Psychopathology 2016 Jul 14;49(4):285-294. [CrossRef] [Medline]
  30. Vismara L, Sechi C, Neri M, Paoletti A, Lucarelli L. Maternal perinatal depression, anxiety, fear of birth, and perception of infants' negative affectivity at three months. J Reprod Infant Psychol 2021 Nov;39(5):532-543. [CrossRef] [Medline]
  31. Townsend R, Chmielewska B, Barratt I, Kalafat E, van der Meulen J, Gurol-Urganci I, et al. Global changes in maternity care provision during the COVID-19 pandemic: A systematic review and meta-analysis. EClinicalMedicine 2021 Jun 18;37:100947 [FREE Full text] [CrossRef] [Medline]
  32. Cena L, Rota M, Calza S, Massardi B, Trainini A, Stefana A. Estimating the Impact of the COVID-19 Pandemic on Maternal and Perinatal Health Care Services in Italy: Results of a Self-Administered Survey. Front Public Health 2021 Jul 16;9:701638 [FREE Full text] [CrossRef] [Medline]
  33. Cena L, Rota M, Calza S, Janos J, Trainini A, Stefana A. Psychological Distress in Healthcare Workers between the First and Second COVID-19 Waves: The Role of Personality Traits, Attachment Style, and Metacognitive Functioning as Protective and Vulnerability Factors. Int J Environ Res Public Health 2021 Nov 11;18(22):11843 [FREE Full text] [CrossRef] [Medline]
  34. Cena L, Rota M, Calza S, Massardi B, Trainini A, Stefana A. Mental Health States Experienced by Perinatal Healthcare Workers during COVID-19 Pandemic in Italy. Int J Environ Res Public Health 2021 Jun 17;18(12):6542 [FREE Full text] [CrossRef] [Medline]
  35. Viaux S, Maurice P, Cohen D, Jouannic J. Giving birth under lockdown during the COVID-19 epidemic. J Gynecol Obstet Hum Reprod 2020 Jun;49(6):101785 [FREE Full text] [CrossRef] [Medline]
  36. Brik M, Sandonis MA, Fernández S, Suy A, Parramon-Puig G, Maiz N, et al. Psychological impact and social support in pregnant women during lockdown due to SARS-CoV2 pandemic: A cohort study. Acta Obstet Gynecol Scand 2021 Jun 02;100(6):1026-1033 [FREE Full text] [CrossRef] [Medline]
  37. Meaney S, Leitao S, Olander EK, Pope J, Matvienko-Sikar K. The impact of COVID-19 on pregnant womens' experiences and perceptions of antenatal maternity care, social support, and stress-reduction strategies. Women Birth 2022 May;35(3):307-316 [FREE Full text] [CrossRef] [Medline]
  38. Bottemanne H, Vahdat B, Jouault C, Tibi R, Joly L. Becoming a Mother During COVID-19 Pandemic: How to Protect Maternal Mental Health Against Stress Factors. Front Psychiatry 2022 Mar 15;12:764207 [FREE Full text] [CrossRef] [Medline]
  39. Vasilevski V, Sweet L, Bradfield Z, Wilson AN, Hauck Y, Kuliukas L, et al. Receiving maternity care during the COVID-19 pandemic: Experiences of women's partners and support persons. Women Birth 2022 May;35(3):298-306 [FREE Full text] [CrossRef] [Medline]
  40. Cena L, Biban P, Janos J, Lavelli M, Langfus J, Tsai A, et al. The Collateral Impact of COVID-19 Emergency on Neonatal Intensive Care Units and Family-Centered Care: Challenges and Opportunities. Front Psychol 2021 Feb 24;12:630594 [FREE Full text] [CrossRef] [Medline]
  41. Oskovi-Kaplan ZA, Buyuk GN, Ozgu-Erdinc AS, Keskin HL, Ozbas A, Moraloglu Tekin O. The Effect of COVID-19 Pandemic and Social Restrictions on Depression Rates and Maternal Attachment in Immediate Postpartum Women: a Preliminary Study. Psychiatr Q 2021 Jun 04;92(2):675-682 [FREE Full text] [CrossRef] [Medline]
  42. Ravaldi C, Wilson A, Ricca V, Homer C, Vannacci A. Pregnant women voice their concerns and birth expectations during the COVID-19 pandemic in Italy. Women Birth 2021 Jul;34(4):335-343 [FREE Full text] [CrossRef] [Medline]
  43. Yan H, Ding Y, Guo W. Mental Health of Pregnant and Postpartum Women During the Coronavirus Disease 2019 Pandemic: A Systematic Review and Meta-Analysis. Front Psychol 2020 Nov 25;11:617001 [FREE Full text] [CrossRef] [Medline]
  44. Ayaz R, Hocaoğlu M, Günay T, Yardımcı OD, Turgut A, Karateke A. Anxiety and depression symptoms in the same pregnant women before and during the COVID-19 pandemic. J Perinat Med 2020 Nov 26;48(9):965-970 [FREE Full text] [CrossRef] [Medline]
  45. Sun F, Zhu J, Tao H, Ma Y, Jin W. A systematic review involving 11,187 participants evaluating the impact of COVID-19 on anxiety and depression in pregnant women. Journal of Psychosomatic Obstetrics & Gynecology 2020 Dec 17;42(2):91-99. [CrossRef]
  46. Tomfohr-Madsen LM, Racine N, Giesbrecht GF, Lebel C, Madigan S. Depression and anxiety in pregnancy during COVID-19: A rapid review and meta-analysis. Psychiatry Res 2021 Jun;300:113912. [CrossRef] [Medline]
  47. Liu CH, Erdei C, Mittal L. Risk factors for depression, anxiety, and PTSD symptoms in perinatal women during the COVID-19 Pandemic. Psychiatry Res 2021 Jan;295:113552 [FREE Full text] [CrossRef] [Medline]
  48. Shayganfard M, Mahdavi F, Haghighi M, Sadeghi Bahmani D, Brand S. Health Anxiety Predicts Postponing or Cancelling Routine Medical Health Care Appointments among Women in Perinatal Stage during the Covid-19 Lockdown. Int J Environ Res Public Health 2020 Nov 09;17(21):8272 [FREE Full text] [CrossRef] [Medline]
  49. Di Mascio D, Khalil A, Saccone G, Rizzo G, Buca D, Liberati M, et al. Outcome of coronavirus spectrum infections (SARS, MERS, COVID-19) during pregnancy: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2020 May;2(2):100107 [FREE Full text] [CrossRef] [Medline]
  50. Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, et al. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. The Lancet 2020 Mar;395(10226):809-815. [CrossRef]
  51. Prochaska E, Jang M, Burd I. COVID-19 in pregnancy: Placental and neonatal involvement. Am J Reprod Immunol 2020 Nov 15;84(5):e13306 [FREE Full text] [CrossRef] [Medline]
  52. Chmielewska B, Barratt I, Townsend R, Kalafat E, van der Meulen J, Gurol-Urganci I, et al. Effects of the COVID-19 pandemic on maternal and perinatal outcomes: a systematic review and meta-analysis. Lancet Glob Health 2021 Jun;9(6):e759-e772 [FREE Full text] [CrossRef] [Medline]
  53. Pathirathna ML, Samarasekara BPP, Dasanayake TS, Saravanakumar P, Weerasekara I. Adverse Perinatal Outcomes in COVID-19 Infected Pregnant Women: A Systematic Review and Meta-Analysis. Healthcare (Basel) 2022 Jan 20;10(2):203 [FREE Full text] [CrossRef] [Medline]
  54. Kazemi SN, Hajikhani B, Didar H, Hosseini SS, Haddadi S, Khalili F, et al. COVID-19 and cause of pregnancy loss during the pandemic: A systematic review. PLoS One 2021 Aug 11;16(8):e0255994 [FREE Full text] [CrossRef] [Medline]
  55. DeSisto CL, Wallace B, Simeone RM, Polen K, Ko JY, Meaney-Delman D, et al. Risk for Stillbirth Among Women With and Without COVID-19 at Delivery Hospitalization - United States, March 2020-September 2021. MMWR Morb Mortal Wkly Rep 2021 Nov 26;70(47):1640-1645 [FREE Full text] [CrossRef] [Medline]
  56. Kersting A, Wagner B. Complicated grief after perinatal loss. Dialogues in Clinical Neuroscience 2022 Apr 01;14(2):187-194. [CrossRef]
  57. Blencowe H, Cousens S, Jassir FB, Say L, Chou D, Mathers C, et al. National, regional, and worldwide estimates of stillbirth rates in 2015, with trends from 2000: a systematic analysis. The Lancet Global Health 2016 Feb;4(2):e98-e108. [CrossRef]
  58. Lawn JE, Blencowe H, Oza S, You D, Lee AC, Waiswa P, et al. Every Newborn: progress, priorities, and potential beyond survival. The Lancet 2014 Jul;384(9938):189-205. [CrossRef]
  59. Heazell AEP, Siassakos D, Blencowe H, Burden C, Bhutta ZA, Cacciatore J, et al. Stillbirths: economic and psychosocial consequences. The Lancet 2016 Feb;387(10018):604-616. [CrossRef]
  60. Maternal and perinatal death and surveillance and response. World Health Organization.   URL: [accessed 2022-04-07]
  61. Testoni I, Bregoli J, Pompele S, Maccarini A. Social Support in Perinatal Grief and Mothers’ Continuing Bonds: A Qualitative Study With Italian Mourners. Affilia 2020 Feb 20;35(4):485-502. [CrossRef]
  62. de Mézerac I, Caeymaex L. Parental mourning after a perinatal loss. Arch Pediatr 2017 Sep;24(9):877-883. [CrossRef] [Medline]
  63. Cena L. Il lutto perinatale. In: Imbasciati A, Cena L, editors. Il futuro dei primi mille giorni di vita. Milan, Italy: Franco Angeli; 2018.
  64. Cena L. Morte endouterina: corporeità materna e dramma perinatale. In: Imbasciati A, Cena L, editors. Il futuro dei primi mille giorni di vita. Milan, Italy: Franco Angeli; 2018.
  65. Cena L, Lazzaroni S. Prendersi cura della Perinatal Death: interventi psicosociali. In: Imbasciati A, Cena L, editors. Il futuro dei primi mille giorni di vita. Milan, Italy: Franco Angeli; 2018.
  66. Ravaldi C, Levi M, Angeli E, Romeo G, Biffino M, Bonaiuti R, et al. Stillbirth and perinatal care: Are professionals trained to address parents' needs? Midwifery 2018 Sep;64:53-59. [CrossRef] [Medline]
  67. Cena L, Nodari L, Lazzaroni S. Perinatal Loss: trauma, dolore e salute mentale dei genitori. In: Imbasciati A, Cena L, editors. Il futuro dei primi mille giorni di vita. Milan, Italy: Franco Angeli; 2018.
  68. Cena L, Stefana A. Psychoanalytic Perspectives on the Psychological Effects of Stillbirth on Parents: A Protocol for Systematic Review and Qualitative Synthesis. Front Psychol 2020 Jun 19;11:1216 [FREE Full text] [CrossRef] [Medline]
  69. Cena L, Lazzaroni S, Stefana A. The psychological effects of stillbirth on parents: A qualitative evidence synthesis of psychoanalytic literature. Z Psychosom Med Psychother 2021 Sep 15;67(3):329-350. [CrossRef] [Medline]
  70. Gold KJ, Leon I, Boggs ME, Sen A. Depression and Posttraumatic Stress Symptoms After Perinatal Loss in a Population-Based Sample. J Womens Health (Larchmt) 2016 Mar;25(3):263-269 [FREE Full text] [CrossRef] [Medline]
  71. Burke L, Neimeyer R. Spiritual Distress in Bereavement: Evolution of a Research Program. Religions 2014 Nov 12;5(4):1087-1115. [CrossRef]
  72. Cacciatore J, DeFrain J, Jones KLC. When a Baby Dies: Ambiguity and Stillbirth. Marriage & Family Review 2008 Nov 14;44(4):439-454. [CrossRef]
  73. Lasker J, Toedter L. The impact of ectopic pregnancy: a 16-year follow-up study. Health Care Women Int 2003 Mar;24(3):209-220. [CrossRef] [Medline]
  74. Gandino G, Di Fini G, Bernaudo A, Paltrinieri M, Castiglioni M, Veglia F. The impact of perinatal loss in maternity units: A psycholinguistic analysis of health professionals' reactions. J Health Psychol 2020 Apr 30;25(5):640-651. [CrossRef] [Medline]
  75. Marwah S, Gaikwad HS, Mittal P. Psychosocial Implications of Stillborn Babies on Mother and Family: A Review from Tertiary Care Infirmary in India. J Obstet Gynaecol India 2019 Jun 6;69(3):232-238 [FREE Full text] [CrossRef] [Medline]
  76. Miller M, Iyer DD, Hawkins C, Freedle A. The impact of COVID-19 pandemic on women's adjustment following pregnancy loss: Brief report. Lindenwood University.   URL: [accessed 2022-04-07]
  77. Inati V, Matic M, Phillips C, Maconachie N, Vanderhook F, Kent AL. A survey of the experiences of families with bereavement support services following a perinatal loss. Aust N Z J Obstet Gynaecol 2018 Feb 28;58(1):54-63. [CrossRef] [Medline]
  78. Flenady V, Oats J, Gardener G, Masson V, McCowan L, Kent A, et al. Clinical practice guideline for care around stillbirth and neonatal death. Stillbirth Centre of Research Excellence. 2020.   URL: https:/​/stillbirthcre.​​wp-content/​uploads/​2021/​03/​Clinical-Practice-Guidelines-for-Care-Around-Stillbirth-and-Neonatal-Death2-2.​pdf [accessed 2022-04-07]
  79. Boyle FM, Horey D, Middleton PF, Flenady V. Clinical practice guidelines for perinatal bereavement care - An overview. Women Birth 2020 Mar;33(2):107-110. [CrossRef] [Medline]
  80. Horey D, Boyle FM, Cassidy J, Cassidy PR, Erwich JJHM, Gold KJ, et al. Parents' experiences of care offered after stillbirth: An international online survey of high and middle-income countries. Birth 2021 Sep 18;48(3):366-374. [CrossRef] [Medline]
  81. Furtado-Eraso S, Escalada-Hernández P, Marín-Fernández B. Integrative Review of Emotional Care Following Perinatal Loss. West J Nurs Res 2021 May 04;43(5):489-504. [CrossRef] [Medline]
  82. Boyle F, Horey D, Dean J, Lohan A, Middleton P, Flenady V. Perinatal bereavement care during COVID-19 in Australian maternity settings. J Perinat Med 2022 Jul 26;50(6):822-831 [FREE Full text] [CrossRef] [Medline]
  83. Flach K, Gressler NG, Marcolino MAZ, Levandowski DC. Complicated Grief After the Loss of a Baby: A Systematic Review About Risk and Protective Factors for Bereaved Women. Trends in Psychol 2022 Jan 10. [CrossRef]
  84. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006 Jan;3(2):77-101. [CrossRef]
  85. Craparo G, Faraci P, Rotondo G, Gori A. The Impact of Event Scale - Revised: psychometric properties of the Italian version in a sample of flood victims. Neuropsychiatr Dis Treat 2013;9:1427-1432 [FREE Full text] [CrossRef] [Medline]
  86. Prigerson HG, Maciejewski PK, Reynolds CF, Bierhals AJ, Newsom JT, Fasiczka A, et al. Inventory of complicated grief: A scale to measure maladaptive symptoms of loss. Psychiatry Research 1995 Nov;59(1-2):65-79. [CrossRef]
  87. Sabourin S, Valois P, Lussier Y. Development and validation of a brief version of the dyadic adjustment scale with a nonparametric item analysis model. Psychol Assess 2005 Mar;17(1):15-27. [CrossRef] [Medline]
  88. Currier JM, Kim S, Sandy C, Neimeyer RA. The factor structure of the Daily Spiritual Experiences Scale: Exploring the role of theistic and nontheistic approaches at the end of life. Psychology of Religion and Spirituality 2012 May;4(2):108-122. [CrossRef]
  89. Burke LA, Neimeyer RA, Holland JM, Dennard S, Oliver L, Shear MK. Inventory of complicated spiritual grief: development and validation of a new measure. Death Stud 2014 Nov 11;38(1-5):239-250. [CrossRef] [Medline]
  90. Boyatzis R. Transforming Qualitative Information: Thematic Analysis and Code Development. Thousand Oaks, California, USA: Sage; 1998.
  91. Nowell LS, Norris JM, White DE, Moules NJ. Thematic Analysis. International Journal of Qualitative Methods 2017 Oct 02;16(1):160940691773384. [CrossRef]
  92. Avelin P, Rådestad I, Säflund K, Wredling R, Erlandsson K. Parental grief and relationships after the loss of a stillborn baby. Midwifery 2013 Jun;29(6):668-673. [CrossRef] [Medline]
  93. Tseng Y, Cheng H, Chen Y, Yang S, Cheng P. Grief reactions of couples to perinatal loss: A one-year prospective follow-up. J Clin Nurs 2017 Dec 06;26(23-24):5133-5142. [CrossRef] [Medline]
  94. Axinn WG, Pearce LD. Mixed Method Data Collection Strategies. New York, US: Cambridge University Press; 2006.

Edited by T Leung; submitted 19.04.22; peer-reviewed by S Cataudella, N Nazari, J Correia; comments to author 27.05.22; revised version received 10.06.22; accepted 06.08.22; published 12.09.22


©Loredana Cena, Alice Trainini, Nella Tralli, Luisa Silvia Nodari, Erika Iacona, Lucia Ronconi, Ines Testoni. Originally published in JMIR Research Protocols (, 12.09.2022.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Research Protocols, is properly cited. The complete bibliographic information, a link to the original publication on, as well as this copyright and license information must be included.