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Pregnant and experiencing intense discomfort, the expectant mother visited the ER after an infection began spreading up her legs. Unemployed and homeless, cut off from her relatives, she lived in a shed she had assembled in a acquaintance's garden. She was also dependent on fentanyl.

As physicians addressed her infection, she started to feel anxious. Withdrawal was setting in. She leaned over the bed and vomited.

Stephanie eventually collapsed. “Listen, I gotta go. I have to go home and take a hit.”

She had used fentanyl before coming to the ER and had only a brief window to get treated before she was compelled to leave to relapse. She thought she still had four weeks left to figure out how to get clean and give birth.

The medical professional intervened. She told Stephanie she was staying put.

“Yes, I am,” Stephanie said.

But the doctors would not let her go: the leg infection was serious, but physicians found she also had an amniotic fluid leak. The nurse, Izzie, warned her: if she left, she and her baby would be at risk of death.

The nurse convinced the doctor to give Stephanie measured quantities of fentanyl at regular intervals, knowing that symptoms could threaten her and the baby. Once the baby was born Stephanie would be transitioned to methadone, a treatment that reduces symptoms and is frequently utilized in substance abuse treatment.

A short time later, on a day in November 2022, Stephanie had a baby girl weighing just over four pounds – early, tiny yet healthy.

When the attendant inquired if she wanted to hold her baby, Stephanie said “I cannot.” She was emotionless. Her epidural had failed, her previous intake of fentanyl had been given a few hours prior to birth.

She felt sick. Unprepared to be a mother. Undeserving.

Stephanie had tried to get clean multiple times while expecting, and felt terrible each time she was unsuccessful. She felt worthless, berating herself for not being able to achieve the unattainable. An obstetrician told her to “just” stop using. Even her source refused to sell to her when she became obviously with child.

“But I couldn’t,” she said. “I had to seek support.”

The pervasive expectation that her affection for her child would make her stop using only led to greater shame and self-abuse, a impetus for her to return to drugs. Yet she could not easily command her addiction away, any more than she could overcome a long-term illness.

The newborn was transferred to the special care nursery. When Stephanie eventually visited her, she was hooked up to monitors, so little she thought she would break her. Holding her for the first time, she felt detached. “I gazed upon her and was like, ‘How will I care for you?’” She remained uncertain she wanted to be her mother.

Two days later she decided to name her baby the same as her nurse, after the professional who provided support to her.

Hospital staff told her about a care center, a unique recovery environment where women and their babies are cared for jointly, not apart.

In numerous states, where a baby is found to have infant withdrawal condition every 18 minutes, infants are still quickly moved to hospitals and treated with pharmaceuticals while their mothers face custody evaluations. But a developing system of centers like this facility is showing an important truth: when families are kept intact, outcomes improve, custody cases decrease and long-term costs decline.

It took Stephanie some time to build confidence to call, but she ultimately reached out. After verifying her eligibility for the program, two staff members came to pick her up.

She departed the institution still in recovery, anxious and doubtful about what would happen next.

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At the facility, Stephanie still worried that authorities would come take Izzie – even though she was not sure she wanted to keep her. The fear lingered: that at any time, someone could enter and separate them.

For the first two weeks, Stephanie stayed withdrawn. “I didn’t really want anything to do with any of them,” she said. “I was suspicious at that point.”

Homelessness, she said, was about getting by. Substances came first; faith came last.

Stephanie had one close friend, but even that connection was tenuous. The those close to her always found ways to cause pain. She lacked the ability to care for herself, not to mention anyone else.

Every day, staff from Maddie’s Place drove her to a clinic for methadone, given as medication. Gradually, she was embracing sobriety.

She spent every minute beyond therapy with Izzie, and could see that her baby was receiving appropriate attention she needed. Her daughter struggled with eating at first, with intolerance to some formulas and pronounced gastrointestinal issues. She needed dietary support. She also had sensory challenges and required an specialist – all typical problems for babies exposed to substances.

If this little kid could see that these babies deserve to be loved, then I found the strength. I could be a mom.

On a day prior to the holiday, Stephanie remained in the shared space, where parents in active addiction can come for supervised visits with their babies. Katie Bunch-Smith, a peer support specialist, came over with her own five kids in tow to deliver baked goods. They all gathered around Stephanie, who was resting on the carpet holding Izzie.

The children were wide-eyed in admiration of the tiny infant in Stephanie’s arms. “They showed no judgment,” Stephanie said. “They overlooked my addiction. None of those things mattered to them.”

She holds a picture of the moment. She is wearing black pants and a hoodie, a gray knit hat with a bobble on her head, resting on the floor with the entryway at her back. She is lean. Her head is tilted forward so you cannot see her face. She is presenting her daughter on her leg for the children to see and they are standing close, admiring and touching to the baby.

One child, eight, asked the mothers: “What about the fathers?” The women attempted to clarify that the dads were busy, called away to other tasks, that they would be there if they could.

“In the future,” Jacob said, “I plan to be a great parent. They will know they are valued.”

Stephanie and the specialist made eye contact. “I just lost it and fell apart,” Stephanie said. “Seeing that even youth understand that infants need affection, then I was able. I could be a mom.”

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Approaches for managing infants affected by substances have existed for decades.

The Finnegan NAS scale was created in 1975|