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Eight months pregnant and in severe pain, the expectant mother visited the ER after a serious infection started to spread up her legs. Without a job or home, separated from loved ones, she resided in a small structure she had assembled in a acquaintance's garden. She was also hooked on fentanyl.

As medical staff managed her infection, she grew increasingly fearful. The onset of withdrawal began. She leaned over the bed and vomited.

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

She had consumed opioids before coming to the ER and had only a brief window to get treated before she was compelled to leave to get high again. She thought she still had four weeks left to figure out how to get clean and have this baby.

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

“Yes, I am,” Stephanie said.

But the hospital refused to discharge her: the condition in her limbs was severe, but doctors had discovered she also had an leakage of amniotic fluid. The nurse, Izzie, warned her: if she left, she and her baby would not survive.

The nurse convinced the doctor to give Stephanie regulated amounts of fentanyl periodically, knowing that withdrawal could endanger her and the baby. After delivery Stephanie would be switched to methadone, a treatment that reduces symptoms and is often prescribed in addiction recovery.

A short time later, on the 12th of November, Stephanie gave birth to a baby girl weighing a small weight – born before term, little but surviving.

When the attendant inquired if she wanted to hold her baby, Stephanie said “I cannot.” She was emotionless. Her pain relief did not work, her previous intake of fentanyl had been provided four hours before delivery.

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

Stephanie had sought recovery several times during pregnancy, and felt awful each time she was unsuccessful. She felt hopeless, criticizing herself for not being able to do the impossible. An obstetrician told her to “only” stop using. Even her dealer would not provide to her when she became clearly expecting.

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

The common assumption that her bond with her newborn would make her stop using only led to deeper self-loathing and self-harm, a trigger for her to relapse. Yet she could not easily command her addiction away, any more than she could will away a long-term illness.

The newborn was transferred to the neonatal intensive care unit. When Stephanie eventually visited her, she was connected to tubes and leads, so tiny she thought she would harm her. Holding her for the first time, 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.

After two days she decided to call her daughter Izzie, after the nurse who had been so kind to her.

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

In many parts of America, where a baby is found to have newborn addiction symptoms frequently, infants are still quickly moved to hospitals and treated with pharmaceuticals while their mothers face child-protection investigations. But a developing system of centers like this facility is showing an important truth: when families are kept intact, outcomes improve, fewer children enter care and overall savings increase.

It took Stephanie a while to gather the courage to call, but she finally did. After verifying her eligibility for the program, a couple of employees came to collect her.

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

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At the facility, Stephanie still worried that authorities would come take Izzie – even though she was hesitant about parenting. The concern persisted: that at any moment, someone could enter and take her baby away.

For the beginning period, Stephanie stayed withdrawn. “I avoided interaction,” she said. “I was suspicious at that point.”

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

Stephanie had one close friend, but even that connection was tenuous. The individuals she cared for always found ways to hurt her. She lacked the ability to care for herself, let alone anyone else.

Each day, staff from the facility took her to a clinic for methadone, administered in pill form. Slowly, she was beginning recovery.

She utilized each moment outside treatment with Izzie, and could see that her baby was obtaining necessary support she needed. Her girl had some trouble feeding at first, with sensitivity to certain foods and pronounced gastrointestinal issues. She needed dietary support. She also had increased sensitivity and required an professional – all frequent conditions for babies exposed to substances.

Seeing that even a young person understands the need for care, then I found the strength. I could parent.

On a day prior to the holiday, Stephanie was in the common room, where those still using can come for guided meetings with their babies. Katie Bunch-Smith, a peer support specialist, came over with her own children in tow to deliver baked goods. They all gathered around Stephanie, who was seated on the ground holding Izzie.

The young ones stared in wonder 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 keeps a photo 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 door behind her. She is lean. Her face is downcast so you cannot see her face. She is holding Izzie up on her lap for the children to see and they are crowding near, showing interest to the baby.

One child, eight, asked the mothers: “Why are there no men?” The women attempted to clarify that the men were occupied, engaged elsewhere, that they would be there given the chance.

“Once I become a parent,” Jacob said, “I’m going to be the best dad ever. They will know they are valued.”

Stephanie and Bunch-Smith exchanged glances. “I broke down,” Stephanie said. “If this little kid could see that infants need affection, then I could do this. I could parent.”

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Approaches for managing drug-exposed newborns have been used for a long time.

The assessment tool was developed in 1975|