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Pregnant and experiencing intense discomfort, a woman named Stephanie visited the hospital emergency room after a serious infection started to spread up her legs. Without a job or home, estranged from her family, she lived in a shed she had constructed in a companion's property. She was also dependent on fentanyl.

As physicians addressed her infection, she began to panic. Withdrawal was setting in. She bent over the bedside and vomited.

Stephanie finally broke down. “I need to leave. I have to go home and use drugs.”

She had taken the drug before coming to the ER and had sufficient opportunity to get treated before she was compelled to leave to relapse. She thought she still had several weeks to find a way to become sober and have this baby.

The nurse had other ideas. She told Stephanie she was staying put.

“I will go,” Stephanie said.

But the doctors would not let her go: the leg infection was severe, but doctors had discovered she also had an ruptured membrane. The nurse, her nurse, warned her: if she walked out, she and her baby would be at risk of death.

The nurse convinced the doctor to give Stephanie controlled doses of fentanyl every few hours, knowing that symptoms could threaten her and the baby. After delivery Stephanie would be switched to methadone, a medication that eases withdrawal and is commonly used in substance abuse treatment.

After five days, on 12 November 2022, Stephanie had a baby girl weighing a small weight – born before term, tiny yet healthy.

When the nurse asked if she wanted to cuddle her newborn, Stephanie said “no.” She was emotionless. Her epidural had failed, her last dose of fentanyl had been given a few hours prior to birth.

She felt ill. Not ready for motherhood. Not fit.

Stephanie had sought recovery multiple times while expecting, and felt awful each time she failed. She felt worthless, criticizing herself for not being able to achieve the unattainable. An doctor told her to “just” stop using. Even her source refused to sell to her when she became clearly expecting.

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

The pervasive expectation that her bond with her newborn would make her stop using only led to greater shame and self-harm, a impetus for her to return to drugs. Yet she could not simply will her addiction away, any more than she could eliminate a persistent condition.

The newborn was transferred to the NICU. When Stephanie at last met her, she was connected to tubes and leads, so small she thought she would break her. Cradling her initially, she felt detached. “I looked at her and was like, ‘What is our future?’” She remained uncertain she wanted to be her mother.

Following a brief period she decided to name her baby Izzie, after the nurse who had been so kind to her.

Medical personnel told her about Maddie’s Place, a innovative treatment home where parents and infants affected by substance use are supported as a unit, not apart.

In much of the US, where a baby is identified with neonatal abstinence syndrome (NAS) every 18 minutes, infants are still whisked to NICUs and medicated while their mothers face parental assessments. But a small, growing network of centers like the care home is showing an important truth: when families are kept intact, recovery succeeds, fewer children enter care and future expenses reduce.

It took Stephanie a while to gather the courage to call, but she eventually made the call. After ensuring she qualified for the program, a couple of employees came to bring her to the facility.

She departed the institution still in detox, scared and uncertain about what would come next.

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At the facility, Stephanie still was concerned that CPS would come take Izzie – even though she was hesitant about parenting. The anxiety remained: that at any point, someone could enter and take her baby away.

For the beginning period, Stephanie kept to herself. “I avoided interaction,” she said. “I was suspicious at that point.”

Life on the streets, she said, was about enduring. Substances came first; faith came last.

Stephanie had one close friend, but even that connection was tenuous. The individuals she cared for always found ways to cause pain. She did not know how to value herself, let alone anyone else.

Each day, staff from the facility took her to a recovery program, administered in pill form. Over time, she was embracing sobriety.

She spent every minute outside treatment with Izzie, and could see that her baby was receiving appropriate attention she needed. Her girl had some trouble feeding at first, with adverse reactions to milk and pronounced gastrointestinal issues. She needed dietary support. She also had heightened sensory issues and required an occupational therapist – all frequent conditions for babies exposed to substances.

When a child recognizes these infants need affection, then I was capable. I would become a mother.

During a pre-holiday visit, Stephanie remained in the shared space, where individuals struggling with substance use can come for supervised visits with their babies. A support specialist, a recovery coach, stopped by with her own children in tow to deliver baked goods. They all crowded near Stephanie, who was sitting on the floor holding Izzie.

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

She has an image of the moment. She is wearing black pants and a hoodie, a cap with a pompom on her head, resting on the floor with the exit nearby. She is lean. Her posture is humble so you miss her features. She is presenting her daughter on her knee for the young ones to see and they are standing close, admiring and touching to the baby.

One child, eight, asked the moms: “Where are all the dads?” The parents responded that the men were occupied, handling responsibilities, that they would be there if they could.

“In the future,” Jacob said, “I’m going to be the best dad ever. I will teach them about love.”

Stephanie and Bunch-Smith exchanged glances. “I broke down,” Stephanie said. “If this little kid could see that these babies deserve to be loved, then I found the courage. I would become a mother.”

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Approaches for managing drug-exposed newborns have been available for years.

The assessment tool was created in 1975|