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Eight months pregnant and in severe pain, Stephanie Rosell arrived at the hospital emergency room after an infection began spreading up her legs. Unemployed and homeless, separated from loved ones, she resided in a small structure she had built in a friend’s yard. She was also addicted to fentanyl.

As doctors treated her infection, she began to panic. The onset of withdrawal began. She slumped forward and threw up.

Stephanie eventually collapsed. “I need to leave. I have to go home and get high.”

She had used fentanyl before seeking medical help and had sufficient opportunity to get treated before she had to return to get high again. She thought she still had four weeks left to figure out how to get clean and deliver her child.

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

“I will go,” Stephanie said.

But the hospital refused to discharge her: the infection in her legs was severe, but doctors had discovered she also had an amniotic fluid leak. The nurse, a caregiver named Izzie, warned her: if she departed, she and her baby would be at risk of death.

She encouraged the doctor to give Stephanie regulated amounts of fentanyl every few hours, knowing that withdrawal could endanger her and the baby. After delivery Stephanie would be placed on methadone, a medication that eases withdrawal and is frequently utilized in substance abuse treatment.

Five days later, on a day in November 2022, Stephanie delivered a daughter weighing 4lb 8oz – born before term, little but surviving.

When the nurse asked if she wanted to cuddle her newborn, Stephanie said “not now.” She was detached. Her epidural had failed, her previous intake of fentanyl had been provided a few hours prior to birth.

She felt sick. Ill-equipped for parenting. Not fit.

Stephanie had sought recovery repeatedly before birth, and felt awful each time she was unsuccessful. She felt hopeless, berating herself for not being able to overcome the challenge. An doctor told her to “just” stop using. Even her dealer declined to supply to her when she became clearly expecting.

“However, I failed,” she said. “I had to seek support.”

The widespread belief that her love for her baby would make her quit only led to greater shame and self-harm, a trigger for her to return to drugs. Yet she could not just wish her addiction away, any more than she could eliminate a chronic disease.

The baby was taken to the neonatal intensive care unit. When Stephanie finally saw her her, she was attached to tubes and leads, so tiny she thought she would break her. Holding her for the first time, she felt empty. “I just stared at her and was like, ‘What is our future?’” She still wasn’t sure she wanted to be her mother.

Two days later she decided to name her baby after her caregiver, after the nurse who had been so kind to her.

Hospital staff told her about a care center, a unique recovery environment where women and their babies are supported as a unit, not apart.

In numerous states, where a baby is diagnosed with neonatal abstinence syndrome (NAS) every 18 minutes, infants are still quickly moved to hospitals and given drugs while their mothers face custody evaluations. But a limited but expanding group of centers like the care home is showing an important truth: when mothers and babies stay together, outcomes improve, custody cases decrease and overall savings increase.

It took Stephanie some time to build confidence to call, but she ultimately reached out. After ensuring she qualified for the program, a couple of employees came to collect her.

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

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At the care center, Stephanie still feared that child services would come seize her child – even though she was not sure she wanted to keep her. The fear lingered: that at any moment, someone could enter and take her baby away.

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

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

Stephanie had a trusted ally, but even that bond was fragile. The individuals she cared for always found ways to let her down. She did not know how to value herself, much less anyone else.

Every day, staff from the facility transported her to a recovery program, administered in pill form. Slowly, she was starting to get clean.

She spent every minute 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 adverse reactions to milk and severe digestive problems. She needed feeding therapy. She also had increased sensitivity and required an professional – 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.

During a pre-holiday visit, Stephanie sat in the visitation area, where parents in active addiction can come for monitored interactions with their babies. A support specialist, a mentor, came over with her own family in tow to bring treats. They all gathered around Stephanie, who was sitting on the floor holding Izzie.

The kids looked amazed in admiration of the small baby in Stephanie’s arms. “They were innocent,” Stephanie said. “My past did not matter to them. None of those things mattered to them.”

She holds a picture of the moment. She is dressed in casual attire, a cap with a pompom on her head, seated on the ground with the door behind her. She is lean. Her head is tilted forward so you do not see her expression. She is presenting her daughter on her knee for the other kids to see and they are standing close, showing interest to the baby.

A young boy, eight, asked the parents: “Why are there no men?” The women attempted to clarify that the dads were busy, handling responsibilities, that they would be there given the chance.

“When I have kids,” Jacob said, “I’m going to be the best dad ever. I’m gonna show them that they deserve to be loved.”

Stephanie and the specialist made eye contact. “I became emotional,” Stephanie said. “Seeing that even youth understand that infants need affection, then I could do this. I would become a mother.”

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

The assessment tool was developed in 1975|