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In her eighth month of pregnancy and suffering, the expectant mother arrived at the hospital emergency room after an infection began spreading up her legs. Unemployed and homeless, separated from loved ones, she stayed in a makeshift shelter she had constructed in a companion's property. She was also addicted to fentanyl.

As medical staff managed her infection, she started to feel anxious. Symptoms of withdrawal emerged. She bent over the bedside and threw up.

Stephanie finally broke down. “I need to leave. I have to go home and take a hit.”

She had used fentanyl before seeking medical help and had only a brief window to get treated before she had to return to use once more. She thought she still had a month remaining to plan her recovery and give birth.

The nurse had other ideas. She told Stephanie she was not going anywhere.

“I am leaving,” Stephanie said.

But the medical facility declined to release her: the condition in her limbs was serious, but doctors had discovered she also had an amniotic fluid leak. The nurse, Izzie, warned her: if she left, she and her baby would not survive.

The nurse convinced the doctor to give Stephanie measured quantities of fentanyl at regular intervals, knowing that abstinence might harm her and the baby. Post-birth Stephanie would be transitioned to methadone, a drug that alleviates cravings and is commonly used in substance abuse treatment.

Five days later, on 12 November 2022, Stephanie delivered a daughter weighing a small weight – early, little but surviving.

When the nurse asked if she wanted to embrace her child, Stephanie said “no.” She was emotionless. Her anesthesia was ineffective, her final administration of fentanyl had been provided a few hours prior to birth.

She felt ill. Not ready for motherhood. Unworthy.

Stephanie had attempted sobriety repeatedly before birth, and felt horrible each time she was unsuccessful. She felt without value, blaming herself for not being able to overcome the challenge. An doctor told her to “just” stop using. Even her supplier refused to sell to her when she became clearly expecting.

“However, I failed,” she said. “I required assistance.”

The pervasive expectation that her affection for her child would make her recover only led to increased guilt and self-abuse, a cause for her to return to drugs. Yet she could not easily command her addiction away, any more than she could eliminate a persistent condition.

The newborn was transferred to the special care nursery. When Stephanie at last met her, she was attached to monitors, so tiny she thought she would harm her. Holding her for the first time, she felt nothing. “I gazed upon her and was like, ‘What is our future?’” She still wasn’t sure she wanted to be her mother.

Following a brief period she decided to call her daughter the same as her nurse, after the attendant who showed compassion to her.

Nurses and doctors told her about a care center, a unique recovery environment where parents and infants affected by substance use are treated together, not apart.

In much of the US, where a baby is identified with neonatal abstinence syndrome (NAS) frequently, infants are still quickly moved to hospitals and medicated while their mothers face custody evaluations. But a developing system of centers like the care home is demonstrating a key fact: when parents and infants remain united, results get better, fewer children enter care and long-term costs decline.

It took Stephanie a while to gather the courage to call, but she finally did. After ensuring she qualified for the program, two staff members came to bring her to the facility.

She stepped out of the hospital still in detox, fearful and unsure about what would happen next.

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At the care center, Stephanie still was concerned that authorities would come remove her daughter – even though she was hesitant about parenting. The anxiety remained: that at any moment, someone could arrive and remove her child.

For the first two weeks, Stephanie kept to herself. “I preferred to be alone,” she said. “I lacked confidence at that point.”

Survival outdoors, she said, was about getting by. Substances came first; reliance came last.

Stephanie had one close friend, but even that bond was fragile. The people she loved always found ways to let her down. She did not know how to value herself, not to mention anyone else.

Daily, staff from Maddie’s Place drove her to a recovery program, provided orally. Over time, she was beginning recovery.

She devoted all her time beyond therapy with Izzie, and could see that her baby was receiving appropriate attention she needed. Her infant faced feeding challenges at first, with sensitivity to certain foods and pronounced gastrointestinal issues. She needed nutritional guidance. She also had sensory challenges and required an occupational therapist – all frequent conditions for babies born with NAS.

When a child recognizes these infants need affection, then I found the strength. I would become a mother.

On a day prior to the holiday, Stephanie sat in the visitation area, where parents in active addiction can come for monitored interactions with their babies. Katie Bunch-Smith, a peer support specialist, came over with her own children in tow to bring treats. They all gathered around Stephanie, who was seated on the ground holding Izzie.

The children were wide-eyed in admiration of the small baby in Stephanie’s arms. “They showed no judgment,” Stephanie said. “They overlooked my addiction. Such issues were irrelevant.”

She has an image of the moment. She is wearing dark trousers and a sweatshirt, a cap with a pompom on her head, sitting on the wooden floor with the entryway at her back. She is lean. Her face is downcast so you miss her features. She is lifting the baby on her lap for the children to see and they are gathered around, fawning and reaching out to the baby.

Jacob, eight, asked the mothers: “What about the fathers?” The women attempted to clarify that the men were occupied, handling responsibilities, that they would be there if they could.

“When I have kids,” Jacob said, “I plan to be a great parent. I will teach them about love.”

Stephanie and Bunch-Smith looked at each other. “I became emotional,” Stephanie said. “If this little kid could see that these babies deserve to be loved, then I could do this. I could be a mom.”

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Approaches for managing drug-exposed newborns have existed for decades.

The assessment tool was established in 1975|