Choose Your Child or Choose Recovery: The Impossible Decision Facing Addicted Mothers

This article was published in partnership with The Marshall Project,  a nonprofit news organization covering the US criminal justice system.

April Lee was still functional in her opioid addiction, still walking her kids to school in Philadelphia, preparing her infant daughter’s bottles, when a sexual assault sent her teetering over the edge.

She had been drugged at a bar and couldn’t identify her attacker. After going to the hospital for help, Lee received a referral to a rape crisis center. But she couldn’t fathom peeling open the trauma, and rehab was also not an option. If she left for treatment, who would take care of her kids while she was gone? Instead, she coped the way she knew how—with substances.

“You take them and you don’t feel anything,” Lee said. “I was able to take the kids back and forth to school. Go to the laundromat, go to the corner store. The drugs made it easier, or so I thought.”

Soon, child welfare authorities arrived and took her children. And eventually, when she couldn’t find treatment, and resorted to sex work to support herself, she was arrested and taken to jail.

I recount April’s harrowing story in my new book, “Rehab: An American Scandal,” out now from Simon & Schuster. The details are uniquely her own. But the theme of her story—a low-income mother who can’t access addiction treatment—is common.

Decades of research have shown that treatment programs that permit women to bring their children have better outcomes. About 70 percent of women struggling with addiction have children, and the lack of child care is one of the top reasons women cite for not seeking help. Yet, when it comes to treating their substance use, mothers face limited options. 

Lawmakers and federal officials have long recognized this. The lack of treatment for mothers was so dire during the crack cocaine epidemic of the 1980s that the federal government instituted a guideline that states set aside 10 percent of treatment and prevention funds for women. Few states ever met that goal.

Then, as the ongoing opioid epidemic began to unfold, lawmakers undertook an unprecedented expansion of treatment. Yet this effort, which added treatment coverage for millions, has had few benefits for pregnant women and women with children.

In fact, I discovered that—since around the start of the opioid epidemic—the number of treatment facilities that cater to patients with children has drastically declined. As of 2023, fewer than 5 percent of all facilities nationwide provide child care for patients, and fewer than 3 percent allow patients to bring their children with them. Pregnant women are routinely turned away from treatment, while others face lengthy wait lists. These problems disproportionately impact Black women, who are much less likely than White women to enter treatment or receive addiction treatment medications. And with recent federal cuts to Medicaid and to addiction treatment that had been expanded during the pandemic, these shortages are likely to get worse.

The result is that women can’t find treatment, even when they want it. “It’s a dead end. There are no facilities out there to help them,” said Eloisa Lopez, a former member of Arizona’s maternal mortality committee. The past couple of years have seen drug overdose deaths overall drop to near pre-pandemic levels. But drug overdoses among mothers have been skyrocketing, and overdoses are one of the leading causes of death during pregnancy. Lopez said many of the overdose deaths the Arizona committee examined occurred after women sought out but couldn’t find treatment.

Even when women find treatment, they can be punished for it. As The Marshall Project has extensively reported, mothers have had their children removed and placed into the foster care system and have been prosecuted for using drugs during their pregnancies, including prescribed addiction treatment medications. Women have also had their children removed after false positive drug tests caused by poppy seed bagels, blood pressure medication, or even the fentanyl from their epidurals during childbirth.

Once incarcerated, women have access to far fewer resources than their male counterparts. Incarcerated people are rarely allowed access to addiction treatment medications like buprenorphine or methadone. And once released, they are especially vulnerable to overdose. One study found that recently released incarcerated people were 40 times more likely to die from opioid overdose than the general population. 

The lack of addiction care for mothers doesn’t just impact them—it hurts their children, too. Studies have found that state policies that punish drug use during pregnancy lead to higher rates of overdose and higher rates of infants born with withdrawal symptoms. Another study found that infants taken from their mothers were significantly less likely to smile, reach, roll over, or sit up compared with other babies who remained with their mothers. And all of this is happening against the backdrop of the Supreme Court’s Dobbs decision, which reversed abortion rights. Women face increasing amounts of surveillance and punishment for certain behaviors during pregnancy.

For April Lee, this is history repeating itself. Her own mother struggled with crack addiction and never had the option of attending treatment. At the time, law enforcement mainly treated addiction as a moral failing, deserving of the harshest punishment, especially in Black communities such as Lee’s. When Lee was a teenager, her mother died from AIDS, likely contracted during her addiction.

“We didn’t have, ‘Oh my God, let’s put them in treatment,’” Lee told me. “It was, ‘Arrest them, separate them.’”

Lee eventually climbed out of her addiction when she entered a recovery home following her arrest. After several years, she reunited with her children, and now she helps other women who’ve had their children removed, often due to substance use. Although treatment access has improved in Philadelphia, she still finds it a challenge to get women into treatment—even when they desperately want it. For many women, that lack of treatment remains a matter of life and death.