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Eight months pregnant and in severe pain, a woman named Stephanie visited the hospital emergency room after an infection began spreading up her legs. Unemployed and homeless, estranged from her family, she resided in a small structure she had built in a companion's property. She was also dependent on fentanyl.

As doctors treated her infection, she began to panic. Withdrawal was setting in. She slumped forward and became sick.

Stephanie eventually collapsed. “I have to get out of here. I have to go home and take a hit.”

She had used fentanyl before arriving at the hospital and had sufficient opportunity to get treated before she had to return to use once more. She thought she still had four weeks left to plan her recovery and give birth.

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

“I am leaving,” Stephanie said.

But the medical facility declined to release her: the infection in her legs was critical, but medical staff detected she also had an leakage of amniotic fluid. The nurse, a caregiver named Izzie, warned her: if she left, she and her baby would not survive.

Izzie persuaded the doctor to give Stephanie controlled doses of fentanyl at regular intervals, knowing that abstinence might harm her and the baby. Post-birth Stephanie would be switched to methadone, a drug that alleviates cravings and is frequently utilized in addiction recovery.

Five days later, on 12 November 2022, Stephanie had a daughter weighing 4lb 8oz – premature, small but alive.

When the caregiver questioned if she wanted to embrace her child, Stephanie said “no.” She was detached. Her epidural had failed, her last dose of fentanyl had been given four hours before delivery.

She felt ill. Ill-equipped for parenting. Undeserving.

Stephanie had tried to get clean multiple times while expecting, and felt awful each time she failed. She felt hopeless, berating herself for not being able to overcome the challenge. An obstetrician told her to “only” stop using. Even her source refused to sell to her when she became obviously with child.

“However, I failed,” she said. “I needed help.”

The pervasive expectation that her bond with her newborn would make her quit only led to increased guilt and negative self-talk, a impetus for her to return to drugs. Yet she could not just wish her addiction away, any more than she could overcome a chronic disease.

The infant was moved to the NICU. When Stephanie at last met her, she was attached to medical equipment, so small she thought she would harm her. Embracing her at last, she felt nothing. “I just stared at her and was like, ‘What am I going to do with you?’” She remained uncertain she wanted to be her mother.

Following a brief period she decided to give her child the name the same as her nurse, after the nurse who had been so kind to her.

Hospital staff told her about a care center, a new kind of care center where parents and infants affected by substance use are treated together, not apart.

In much of the US, where a baby is found to have neonatal abstinence syndrome (NAS) frequently, infants are still quickly moved to hospitals and medicated while their mothers face parental assessments. But a developing system of centers like Maddie’s Place is proving a simple point: when parents and infants remain united, outcomes improve, 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 confirming she would be a good fit for the program, care providers came to bring her to the facility.

She left the medical center still in detox, scared and uncertain about what would follow.

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At the facility, Stephanie still worried that child services would come take Izzie – even though she was hesitant about parenting. The fear lingered: that at any moment, someone could enter and separate them.

For the beginning period, Stephanie stayed withdrawn. “I preferred to be alone,” she said. “I was suspicious at that point.”

Life on the streets, she said, was about getting by. Addiction came first; reliance came last.

Stephanie had a single companion, but even that connection was tenuous. The those close to her always found ways to cause pain. She was unable to value herself, let alone anyone else.

Every day, staff from the facility took her to a treatment center, given as medication. Gradually, she was embracing sobriety.

She spent every minute when not in sessions with Izzie, and could see that her baby was receiving appropriate attention she needed. Her daughter struggled with eating at first, with adverse reactions to milk and obvious stomach troubles. She needed nutritional guidance. She also had heightened sensory issues and required an occupational therapist – all common issues for babies exposed to substances.

Seeing that even a young person understands the need for care, then I could do this. I would become a mother.

One afternoon before Thanksgiving, Stephanie was in the common room, where those still using can come for guided meetings with their babies. Katie Bunch-Smith, a mentor, came over with her own five kids in tow to bring treats. They all crowded near Stephanie, who was sitting on the floor holding Izzie.

The young ones stared in wonder of the little newborn in Stephanie’s arms. “They showed no judgment,” Stephanie said. “They overlooked my addiction. Such issues were irrelevant.”

She keeps a photo of the moment. She is wearing black pants and a hoodie, a beanie with a bobble on her head, resting on the floor with the entryway at her back. She is thin. Her face is downcast so you miss her features. She is presenting her daughter on her knee for the other kids to see and they are crowding near, admiring and touching to the baby.

A young boy, eight, asked the parents: “Why are there no men?” The women attempted to clarify that the men were occupied, called away to other tasks, that they would be there given the chance.

“In the future,” Jacob said, “I will excel as a father. I will teach them about love.”

Stephanie and the specialist made eye contact. “I became emotional,” Stephanie said. “Seeing that even youth understand that these babies deserve to be loved, then I could do this. I would become a mother.”

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

The assessment tool was established in 1975|