Meet the Death Doula Who Helps People Deal with the 'Bookends of Life'

"Birth and death are what give shape to our lives," Saba told me during a phone interview. "They are the bookends. If we don't acknowledge the opening and the closing, our story feels disconnected in between."

For someone immersed in the transformational moments of other people's lives, it is perhaps not surprising that Saba's own life has been characterized by change. Born and raised on Staten Island, Saba majored in physics and philosophy at CUNY–College of Staten Island and went on to work as a child abuse investigator with the Society for Prevention of Cruelty to Children; a production assistant and event planner with MTV; a project coordinator for a wine and spirit distributor; a reservations representative with American Airlines; and a life coach. She also homeschooled her two sons and owns multiple patents for educational toys, games, and products.

Somewhere during this peripatetic sequence of careers, Saba developed an interest in midwifery. She said her work in parenting education sparked a desire to participate in her clients' lives, and those of their children, at an earlier, more formational point.

"Through a lot of my work, I started to see how [people] enter parenting, [and their expectations] develop during pregnancy and birth, which is why I transitioned into the birth work," Saba said.

Saba began shadowing an experienced midwife in 2007 but realized she felt more drawn to work as a doula—someone who focuses on supporting mothers as they give birth rather than on "baby catching." While pregnant women certainly need physical support, Saba felt that emotional support and education were just as essential components of a healthy birth, and often undervalued.

"I wanted to try and do birth better," she said. "It began as a side thing. I wanted to help my family and friends, and then it grew."

Melissa Harley, a certified doula and DONA's PR director, said that DONA has certified 12,000 doulas since its founding, with 10,000 certified after 2002. In the past two years, the number of certified doulas has increased by 30 percent, and awareness is growing thanks to emerging research, as well as documentaries that show what doulas do.

"The public has become more and more aware of the services a doula provides as well as the benefits of the doula's role as part of the maternity care team," Harley said. "There are lots of reasons why families seek the support of a doula, and as more research comes out about the cost-reducing physical and mental health benefits of the doula, we're also seeing insurance companies begin to reimburse for doula services, as well as Medicaid programs that offer doula support."

Since she started training to become a doula, Saba has helped deliver over 1,200 babies. From there, ironically, or tragically, she started thinking about death.

"Statistically, with 1,200 babies, it's inevitable you are going to see some losses," Saba said. "Increasingly, people were calling on me to help because they knew someone who'd had a stillbirth, or [because] a baby's heartbeat stopped."

Saba was a natural person for grieving families to call, not only because of her reputation for providing emotional support in intimate situations but also because of her comfort with and around death. She first encountered death at age four, while playing with a friend who suddenly died of an asthma attack. When she was 11, she discovered a friend's mother slumped over the oven door in the kitchen where she had collapsed from a stroke while baking cookies. Saba's friend screamed and ran to get help; Saba stayed with the body. Years later, Saba and her family dealt with the loss of 41 people they knew who were killed on 9/11.

"I went to a school where boys were stockbrokers or firefighters, and that's who died on 9/11," she said. "I gained a lot of experience planning funeral after funeral and learning how to support people through them. Then my brother died in Iraq. I've been through loss and have a lot of experience around death."

Saba was also diagnosed with cancer when her children were young, which she said forced her to "really look at what death would mean." All these experiences thrust her unwittingly into the role of a death doula, years before the concept or term began to gain traction in the US.

"I became more and more fascinated by the people who called for [death] support," Saba said. "I was hesitant to even call myself a death doula, but I saw that as people became more educated and informed about death, when they got their fear out of the way it was like this weight had been lifted."

Saba began seeking clients in a death doula capacity, working with dying individuals, and often their families, to prepare for the event. The concept of an end-of-life doula emerged in the early 2000s when a hospice volunteer and social worker, Henry Fersko-Weiss, founded the International End of Life Doula Association (INELDA). After going through training as a birth doula, he realized that the concepts he learned could be applied to the dying and their families, too. Fersko-Weiss, along with Janie Rakow and Meredith Lawida, established the INELDA in 2003 to raise awareness about the practice and create a national network of doulas.

"Our whole model was really founded and based upon the birth doula model, taking that same concept and applying it to another life transition," said Jeri Glatter, the vice president of INELDA. "Our hope is to fill some of the gaps that exist within the medical community with end-of-life care."

Before 1900, birth and death were overseen by women at home, but around the turn of the century, this division of labor began to shift. Birth was medicalized and transitioned to hospitals, where it was governed by male physicians. Between 1900 and 1950, the number of women delivering babies in hospitals increased from less than 5 percent to 80 percent. Today, over 98 percent of US births happen in hospitals.

Women seek out birth doulas for a variety of reasons. Some are nervous first-time mothers who want help processing the overwhelming tide of information and conflicting opinions. Others have had multiple children and were unhappy with the care they received in hospitals. Doulas can be critical allies for women who do not want interventions during childbirth. One in three women who give birth in the US has a cesarean delivery, which is three times what the World Health Organization considers the "ideal rate." Not only are the interventions overused, but they can also happen against the wishes of the mother. According to the Listening to Mothers Survey, published by the nonprofit organization Childbirth Connection, around 15 percent of women reported feeling pressure from a health professional to accept an intervention.

One of the main roles of a doula, especially those practicing in hospitals, is to help mothers express their wishes and resist needless pressure. These efforts yield results. A meta-analysis of support for women during childbirth by the nonprofit research NGO Cochraneinvolving more than 15,000 people found that mothers who receive continuous labor support are less likely to have interventions during birth, more likely to be satisfied with the experience, and more likely to deliver babies with better Apgar stores (which measure a baby's condition at birth).

Death care is experiencing a similar pattern—from the home to the institution and back again. After the Civil War (and the development of embalming), the practice of body preparation was professionalized and industrialized. More recently, advancements in medical technology and palliative care have led to more people being hospitalized at the end of their lives, leading to more deaths in acute care hospitals and nursing homes. As with birth doulas, the increase in end-of-life doula services is part of a growing movement away from this institutionalization. People don't want to feel like a "system" or like strangers are making critical decisions for them.

Jeri Glatter, of INELDA, said the number of end-of-life doulas is growing every year and that she has noticed an uptick in the number of birth doulas who go through the end-of-life training program to add to their practice. The differences between birth doulary and death doulary are not as different as one might expect, and in fact, Saba said each practice informs the other. As demand for both her services continued to grow, so did interest in her method, which she describes as a Socratic-influenced "coaching model."

In 2009, Saba began conducting live trainings for birth doulas and founded the Momdoulary Doula Training Program, which she brought online in 2011. She now teaches 50 students a year. She also started training end-of-life doulas through live apprenticeships and formed the Momdoulary Death & Mourning Doula Training Program, which also offers training online, in 2013.

"I've found that what creates a great birth experience is also what creates a great death experience," Saba said. "I question people to help them identify the things that are most important to them, the things that make them most anxious, and go through practice vignettes to get used to the language."

For example, if a woman in labor wants to forego an epidural against the advice of her mother, or if a family member's wishes for a funeral do not align with those of their loved ones, Saba can help parties on all sides prepare for difficult conversations. The notion of a "great death experience" may seem strange, but to Saba, it's all about helping someone find peace and comfort in their last days.

"We have this habit of treating both birth and death like emergencies, when most of the time, they can be normal, relaxed, and slow," Saba said. " With loss and with babies, what you really get is a new normal."

The reassurance of normalcy is a core part of a doula's work. Family members and friends, often wrapped up in the emotional tempest of what is happening to their loved one, may not be able to provide the calm and reason of an experienced third party. And medical providers with tenuous connections to the patient— as well as multiple cases to attend—may not be able to offer the intimacy that can be essential to assuaging fears and settling anxieties.

"What I've come to see as the biggest influence on both ends of life are the stories that we tell ourselves," Saba said, referring to misconceptions and expectations about birth and death she believes are fueled by the media. "I thought it was an anomaly when I was working with birth, and then I get to death and see same thing. The stories we tell shape the expectations we have and impact how we meet them and how experiences play out for us."

One of the most distinctive aspects of Saba's approach is her flexibility and responsiveness, which she sees as antidotes to expectations. The expectation of pain may cause a birthing women to feel fear, while setting expectations of what she wants for her birth can create a sense of order and control. That isn't necessarily a good thing: Every situation is different, and there are too many variables—how a client slept the night before, what they've eaten, or whether they fought with a partner—that may throw a plan off course.

"I buck the trend of doulas on both sides who say, 'We are going to make a birth or death plan,'" Saba said. "I find that planning doesn't really work. The best laid plans are the ones that fastest go off track, and no matter what you do, you can never truly be prepared completely."

That willingness to be present and adaptable is not just something Saba advises for her clients—it's how she lives her own life. On any given day, Saba may go back and forth between a pregnant woman and a hospice patient, and middle-of-the-night calls are part and parcel of the job. Attending birth and death is also intensely emotional work, with moments of extreme feeling punctuated by lulls. Being present is just as necessary for Saba as it is for the people she works with.

Though it is sometimes exhausting, Saba finds that helping others access the most profound moments in their lives in turn provides her with a deep sense of connection and purpose in her own.

"Ritual is so important, and we've eliminated a lot of ritual by putting women asleep for their birth experience or sending [the elderly] away to a nursing home to die," Saba said. "Now folks are looking to reconnect with these things, and it's very rewarding. I feel like I never have to doubt the meaning of my work."