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In her eighth month of pregnancy and suffering, the expectant mother arrived at the hospital emergency room after her infection worsened up her legs. Unemployed and homeless, separated from loved ones, she stayed in a makeshift shelter she had built in a companion's property. She was also hooked on fentanyl.

As doctors treated her infection, she grew increasingly fearful. The onset of withdrawal began. She bent over the bedside and became sick.

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 seeking medical help and had sufficient opportunity to get treated before she was compelled to leave to relapse. She thought she still had several weeks to find a way to become sober and give birth.

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

“Yes, I am,” Stephanie said.

But the hospital refused to discharge her: the leg infection was severe, but medical staff detected she also had an ruptured membrane. The nurse, Izzie, warned her: if she left, she and her baby would face grave danger.

The nurse convinced the doctor to give Stephanie regulated amounts of fentanyl at regular intervals, knowing that symptoms could threaten her and the baby. After delivery Stephanie would be transitioned to methadone, a medication that eases withdrawal and is often prescribed in substance abuse treatment.

Five days later, on 12 November 2022, Stephanie delivered a daughter weighing 4lb 8oz – early, little but surviving.

When the caregiver questioned if she wanted to hold her baby, Stephanie said “not now.” 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. Unprepared to be a mother. Undeserving.

Stephanie had tried to get clean several times during pregnancy, and felt horrible each time she was unsuccessful. She felt worthless, blaming herself for not being able to overcome the challenge. An doctor told her to “simply” stop using. Even her dealer refused to sell to her when she became clearly expecting.

“Yet I was unable,” she said. “I required assistance.”

The common assumption that her bond with her newborn would make her quit only led to increased guilt and negative self-talk, a cause for her to use again. Yet she could not just wish her addiction away, any more than she could overcome a long-term illness.

The newborn was transferred to the NICU. When Stephanie eventually visited her, she was hooked up to tubes and leads, so little she thought she would harm her. Holding her for the first time, she felt detached. “I looked at her and was like, ‘How will I care for you?’” She still wasn’t sure she wanted to be her mother.

Two days later she decided to call her daughter Izzie, after the attendant who showed compassion to her.

Medical personnel told her about a care center, a innovative treatment home where parents and infants affected by substance use are cared for jointly, not apart.

In much of the US, where a baby is diagnosed with newborn addiction symptoms regularly, infants are still whisked to NICUs and treated with pharmaceuticals while their mothers face child-protection investigations. But a small, growing network of centers like this facility is demonstrating a key fact: when parents and infants remain united, results get better, foster placements fall and future expenses reduce.

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 collect her.

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

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At the care center, Stephanie still worried that child services would come take Izzie – even though she was not sure she wanted to keep her. The concern persisted: that at any point, someone could walk in and separate them.

For the first two weeks, Stephanie stayed withdrawn. “I avoided interaction,” she said. “I didn’t have a lot of trust at that point.”

Survival outdoors, she said, was about getting by. Drugs came first; faith came last.

Stephanie had one close friend, but even that connection was tenuous. The individuals she cared for always found ways to cause pain. She was unable to care for herself, not to mention anyone else.

Daily, staff from the facility took her to a recovery program, administered in pill form. Slowly, she was beginning recovery.

She devoted all her time outside treatment with Izzie, and could see that her baby was receiving appropriate attention she needed. Her infant faced feeding challenges at first, with intolerance to some formulas and obvious stomach troubles. She needed dietary support. She also had sensory challenges and required an professional – all frequent conditions for babies born with NAS.

When a child recognizes these infants need affection, then I could do this. I could be a mom.

One afternoon before Thanksgiving, Stephanie sat in the visitation area, where individuals struggling with substance use can come for monitored interactions with their babies. Katie Bunch-Smith, a mentor, came over with her own five kids in tow to deliver baked goods. They all gathered around Stephanie, who was sitting on the floor holding Izzie.

The kids looked amazed in wonder of the little newborn in Stephanie’s arms. “They were innocent,” Stephanie said. “They overlooked my addiction. None of those things mattered to them.”

She holds a picture of the moment. She is wearing casual attire, a beanie with a pompom on her head, seated on the ground with the entryway at her back. She is slender. Her posture is humble so you do not see her expression. She is holding Izzie up on her leg for the children to see and they are gathered around, fawning and reaching out to the baby.

One child, eight, asked the moms: “Why are there no men?” The parents responded that the fathers had obligations, engaged elsewhere, that they would be there given the chance.

“When I have kids,” Jacob said, “I plan to be a great parent. They will know they are valued.”

Stephanie and the specialist looked at each other. “I became emotional,” Stephanie said. “When a child recognized that these babies deserve to be loved, then I could do this. I could parent.”

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

The Finnegan NAS scale was established in 1975|