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Eight months pregnant and in severe pain, Stephanie Rosell visited the ER after a serious infection started to spread up her legs. Without a job or home, estranged from her family, she resided in a small structure she had built in a companion's property. She was also hooked on fentanyl.

As medical staff managed her infection, she started to feel anxious. Withdrawal was setting in. She bent over the bedside and vomited.

Stephanie finally broke down. “I have to get out of here. I have to go home and get high.”

She had taken the drug before coming to the ER and had sufficient opportunity to get treated before she had to return to get high again. She thought she still had several weeks to plan her recovery and deliver her child.

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 infection in her legs was critical, but doctors had discovered she also had an amniotic fluid leak. The nurse, her nurse, warned her: if she left, she and her baby would not survive.

She encouraged the doctor to give Stephanie regulated amounts of fentanyl periodically, knowing that abstinence might harm her and the baby. After delivery Stephanie would be placed on methadone, a treatment that reduces symptoms and is frequently utilized in addiction recovery.

A short time later, on 12 November 2022, Stephanie had a baby girl weighing 4lb 8oz – born before term, small but alive.

When the attendant inquired if she wanted to cuddle her newborn, Stephanie said “I cannot.” She was emotionless. Her pain relief did not work, her last dose of fentanyl had been provided a few hours prior to birth.

She felt unwell. Not ready for motherhood. Unworthy.

Stephanie had sought recovery several times during pregnancy, and felt horrible each time she failed. She felt worthless, blaming herself for not being able to do the impossible. An OBGYN told her to “just” stop using. Even her source declined to supply to her when she became visibly pregnant.

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

The widespread belief that her bond with her newborn would make her recover only led to increased guilt and negative self-talk, a cause for her to relapse. Yet she could not simply will her addiction away, any more than she could will away a persistent condition.

The newborn was transferred to the special care nursery. When Stephanie eventually visited her, she was hooked up to medical equipment, so small she thought she would hurt her. Cradling her initially, she felt detached. “I gazed upon her and was like, ‘What is our future?’” She continued to doubt she wanted to be her mother.

Following a brief period she decided to give her child the name Izzie, after the attendant who showed compassion to her.

Medical personnel told her about a specialized facility, a unique recovery environment where women and their babies are treated together, not apart.

In much of the US, where a baby is diagnosed with neonatal abstinence syndrome (NAS) frequently, infants are still quickly moved to hospitals and treated with pharmaceuticals while their mothers face custody evaluations. But a limited but expanding group of centers like Maddie’s Place is demonstrating a key fact: when parents and infants remain united, results get better, foster placements fall and long-term costs decline.

It took Stephanie a period to find strength to call, but she ultimately reached out. After ensuring she qualified for the program, care providers came to pick her up.

She left the medical center still in withdrawal, anxious and doubtful about what would come next.

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At Maddie’s Place, Stephanie still was concerned that CPS would come take Izzie – even though she was uncertain about motherhood. The fear lingered: that at any moment, someone could enter and remove her child.

For the beginning period, Stephanie remained isolated. “I avoided interaction,” she said. “I lacked confidence at that point.”

Life on the streets, she said, was about enduring. Addiction came first; trust came last.

Stephanie had a single companion, but even that connection was tenuous. The people she loved always found ways to cause pain. She lacked the ability to care for herself, much less anyone else.

Every day, staff from the facility transported her to a clinic for methadone, provided orally. Slowly, she was beginning recovery.

She utilized each moment when not in sessions with Izzie, and could see that her baby was receiving appropriate attention she needed. Her infant faced feeding challenges at first, with sensitivity to certain foods and pronounced gastrointestinal issues. She needed dietary support. She also had heightened sensory issues and required an specialist – all frequent conditions for babies born with NAS.

Seeing that even a young person understands the need for care, then I found the strength. I would become a mother.

During a pre-holiday visit, Stephanie was in the common room, where parents in active addiction can come for monitored interactions with their babies. Katie Bunch-Smith, a peer support specialist, stopped by with her own children in tow to drop off cookies. They all crowded near Stephanie, who was sitting on the floor holding Izzie.

The kids looked amazed in wonder of the tiny infant in Stephanie’s arms. “They had no care in the world,” Stephanie said. “They didn’t care that I had used drugs with her. Such issues were irrelevant.”

She has an image of the moment. She is wearing casual attire, a cap with a pompom on her head, seated on the ground with the entryway at her back. She is thin. Her face is downcast so you cannot see her face. She is presenting her daughter on her leg for the children to see and they are crowding near, showing interest to the baby.

A young boy, eight, asked the moms: “Why are there no men?” The parents responded that the fathers had obligations, called away to other tasks, that they would be there given the chance.

“When I have kids,” Jacob said, “I will excel as a father. I will teach them about love.”

Stephanie and Bunch-Smith exchanged glances. “I became emotional,” Stephanie said. “When a child recognized 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 Finnegan NAS scale was developed in 1975|