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Eight months pregnant and in severe pain, Stephanie Rosell visited the hospital emergency room after a serious infection started to spread up her legs. Without a job or home, cut off from her relatives, she lived in a shed she had constructed in a companion's property. She was also addicted to fentanyl.

As physicians addressed her infection, she grew increasingly fearful. Withdrawal was setting in. She bent over the bedside and vomited.

Stephanie ultimately gave in. “I need to leave. I have to go home and use drugs.”

She had consumed opioids before arriving at the hospital and had just enough time to get treated before she had to return to relapse. She thought she still had a month remaining to figure out how to get clean and deliver her child.

The attending nurse disagreed. She told Stephanie she was not going anywhere.

“I will go,” Stephanie said.

But the doctors would not let her go: the leg infection was serious, but physicians found she also had an ruptured membrane. The nurse, 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 abstinence might harm her and the baby. Once the baby was born Stephanie would be placed on methadone, a medication that eases withdrawal and is commonly used in substance abuse treatment.

A short time later, on the 12th of November, Stephanie delivered a daughter weighing just over four pounds – born before term, little but surviving.

When the nurse asked if she wanted to embrace her child, Stephanie said “I cannot.” She was emotionless. Her epidural had failed, her last dose of fentanyl had been provided a few hours prior to birth.

She felt ill. Not ready for motherhood. Undeserving.

Stephanie had tried to get clean multiple times while expecting, and felt horrible each time she failed. She felt without value, criticizing herself for not being able to overcome the challenge. An OBGYN told her to “simply” stop using. Even her supplier would not provide to her when she became obviously with child.

“Yet I was unable,” she said. “I had to seek support.”

The common assumption that her affection for her child would make her recover only led to increased guilt and negative self-talk, a impetus for her to return to drugs. Yet she could not simply will her addiction away, any more than she could eliminate a long-term illness.

The infant was moved to the special care nursery. When Stephanie at last met her, she was hooked up to medical equipment, so tiny she thought she would break her. Holding her for the first time, she felt detached. “I gazed upon her and was like, ‘How will I care for you?’” She remained uncertain she wanted to be her mother.

After two days she decided to name her baby after her caregiver, after the professional who provided support to her.

Hospital staff told her about a specialized facility, a unique recovery environment where parents and infants affected by substance use are treated together, not apart.

In many parts of America, where a baby is identified with neonatal abstinence syndrome (NAS) regularly, infants are still whisked to NICUs and medicated while their mothers face parental assessments. But a small, growing network of centers like this facility is proving a simple point: when families are kept intact, outcomes improve, fewer children enter care and overall savings increase.

It took Stephanie some time to build confidence to call, but she eventually made the call. After ensuring she qualified for the program, two staff members came to bring her to the facility.

She left the medical center still in withdrawal, fearful and unsure about what would follow.

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

For the initial fortnight, Stephanie kept to herself. “I preferred to be alone,” she said. “I didn’t have a lot of trust at that point.”

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

Stephanie had a single companion, but even that relationship was delicate. The those close to her always found ways to cause pain. She lacked the ability to love herself, much less anyone else.

Every day, staff from Maddie’s Place took her to a clinic for methadone, administered in pill form. Over time, she was embracing sobriety.

She devoted all her time outside treatment with Izzie, and could see that her baby was getting the specialized care she needed. Her daughter struggled with eating at first, with sensitivity to certain foods and severe digestive problems. She needed dietary support. She also had sensory challenges and required an specialist – all frequent conditions for babies exposed to substances.

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

One afternoon before Thanksgiving, Stephanie was in the common room, where parents in active addiction can come for guided meetings with their babies. A support specialist, a mentor, visited 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 wonder of the little newborn in Stephanie’s arms. “They had no care in the world,” Stephanie said. “They didn’t care that I had used drugs with her. They focused only on the baby.”

She has an image of the moment. She is dressed in dark trousers and a sweatshirt, a beanie with a pompom on her head, seated on the ground with the exit nearby. She is thin. Her head is tilted forward so you do not see her expression. She is lifting the baby on her knee for the other kids to see and they are crowding near, showing interest to the baby.

One child, eight, asked the parents: “Why are there no men?” The parents responded that the men were occupied, handling responsibilities, that they would be there if they could.

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

Stephanie and her companion looked at each other. “I became emotional,” Stephanie said. “Seeing that even youth understand that these babies deserve to be loved, then I found the courage. I would become a mother.”

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Approaches for managing babies with exposure have existed for decades.

The assessment tool was created in 1975|