For two hours every Saturday, a 1960s-era bus parks on a dead-end street in a dusty part of Fresno, California. Volunteers set up tarps and chairs on the sidewalk and people roll up in cars or on foot, pushing shopping carts or strollers. They’re here to dump their dirty syringes, sometimes hundreds at a time, and exchange them for clean ones. Providing this particular service in this particular location is crucial. Fresno is the poorest large city (with more than 250,000 residents) in California and in Fresno County, drug use is about twice the state average, according to the Fresno County Public Health Department.
Everyone at the needle exchange has a story about the life-altering moment they first injected drugs. A 30-something woman with wavy brown hair says that six months ago, before she started injecting meth, she was a “soccer mom” with a husband and kids, living in a nice home. Now she’s squatting in an abandoned building, waiting until the police discover her and kick her out. Another woman says she’d never tried drugs before a doctor prescribed her opioid painkillers. After her prescription ran out, buying pills cost her $200 to 300 a day. She started using heroin because it was cheaper, only $100 a day.
A woman with curly hair sitting on an aluminum chair says her name is Amanda (she asked that we use only her first name to protect her privacy). She’s addicted to heroin and meth—and she just found out that she’s five months pregnant. Over the course of the next four months, Amanda will learn what it means to give up drugs for her pregnancy—what she’ll have to do in order to keep her baby.
Amanda is 30 years old and has three kids— sons aged 14 and 12, and a 4-year-old daughter— who all live with their dads. She still sees them , usually weekly , and shares custody, but she doesn’t feel like she can take care of them due to her drug use and lack of stable housing. Amanda tells me that she’s homeless and has been staying at a motel nearby. She wants to continue the pregnancy; she doesn’t believe in abortion and wonders if the baby has a greater purpose. “Maybe that’s one of the reasons God got me pregnant — so I can get off this shit.”
According to a 2012 study, about 6 percent of pregnant women in the United States use illicit drugs. Maternal drug use has both emotional effects on the mother and physical repercussions on the child, such as low birthweight, respiratory problems, and mortality. Pregnancy can be a crucial time to address substance abuse, because women are almost certain to intersect with medical practitioners. In one study, 83 percent of pregnant women who were using cigarettes, alcohol, cocaine, or marijuana, were able to stop during pregnancy, though relapses afterward were very common. Nationally, about a third of children entering foster care do so due to parental drug abuse, according to 2016 data.
In California, from 2008 to 2015, the number of infants exposed to drugs via the placenta or through breast milk almost doubled, according to California’s Office of Statewide Health Planning and Development. But in the state, Child Protective Services, or CPS, can’t get involved when a woman is pregnant, even if she’s actively using drugs. As soon as a baby is born, CPS can open up a case and place the baby with a family member or a foster family if they believe a mother’s drug use poses substantial risk to the child. Last year in Fresno County, 93 infants were taken from their mothers due to drug use, or six out of every 1,000 babies. That figure is up slightly from 83 infants in 2014, when CPS first started tracking such data. Amanda knows CPS’ process intimately: Her daughter was temporarily taken away at birth because she tested positive for marijuana and meth. If Amanda keeps using, the same could happen to her new baby.
Amanda found out she was pregnant when she went to a doctor for an unrelated medical exam. She said she had felt the baby move, but was in denial about the pregnancy. The fact that Amanda was reticent to accept her pregnancy isn’t surprising. Stigma is a common barrier to care for pregnant drug users. Many people at the needle exchange said doctors treat them poorly—they’re brusque or don’t give enough local anesthetic, for example—when they realize they are injection-drug users.
The motel where Amanda lives — when she has enough money — is on what people in Fresno call “Motel Drive,” a row of run-down establishments serving people struggling in Fresno’s economy. Amanda has a boyfriend, whom she calls “Twin,” who stays with her at the motel. She pays anywhere from $45 to $55 a night, and when she lapses on rent she moves to a different motel or stays in her car. In total, her monthly rent is about $1,500—more than twice the average for a two-adult household in Fresno County. While the cost is significantly higher, motel living gives Amanda the option to pay each day individually—a crucial option for someone without a stable income.
Amanda makes her money through sex work. She charges about $40 a date and meets people in cars or in tucked away corners of the city because the motels have strict rules against visitors. About $20 of Amanda’s daily income goes to buying black-tar heroin, which she calls “black,” and she spends her spare money on meth. She mixes the two drugs together because she likes the high better. Amanda used to spend more on drugs but she says she’s cut down since she found out she was pregnant.
For women, substance abuse correlates with sex work, and drug abusers report high rates of poverty, intimate-partner violence, and mental illness. Amanda’s life includes many of these factors: She has been diagnosed with bipolar disorder and borderline personality disorder. She says Twin has a history of violence against her, and records I reviewed show that he’s been incarcerated for battery as recently as 2016. While Twin was in prison, Amanda had an affair with one of her clients, who she thinks is most likely the father of the baby.
David Abel, a perinatologist (an obstetrician who specializes in high-risk pregnancies), says he commonly encounters patients like Amanda. “Mom usually has a lack of support. She may be homeless. She’s often in a dysfunctional relationship. Sometimes intimate-partner violence is involved,” he explains. “She’s very poor, doesn’t have a job, and also may have an accompanying mental illness.”
Amanda first tried drugs at 14, when she snorted crystal meth with her older sister and a friend. She had her first child at 17, then got married. For the seven years she was with her husband, she stayed sober, but when she left him she started using meth again. That’s also when she began working as a prostitute.
It wasn’t long after separating from her husband that she tried heroin. “Heroin has controlled my life from the moment I injected it,” she says. Since she started using heroin, she’s only stopped once — for 12 days. Heroin has incredibly painful withdrawal symptoms. Amanda described them as “like the flu, but times 30,000.” Many people at the needle exchange told me they use just enough heroin to prevent the horrible withdrawals and don’t even get high anymore.
At her six-month ultrasound appointment, a doctor tells Amanda that her baby is healthy. But Amanda’s honest about her continued drug use, and her doctor encourages her to go into a methadone program to treat her heroin addiction. Methadone is considered safer than heroin because its longer half-life reduces cravings and the risk of withdrawal, which is important because the ups and downs associated with heroin are considered hazardous for a fetus. And methadone is manufactured under controlled conditions, so it’s thought to be less dangerous than street drugs, which are often “cut” or mixed with low-quality ingredients — such as sugar or caffeine — so drug dealers can bulk up their supply. Women treated with methadone also demonstrate fewer of the behaviors associated with heroin use, like prostitution, and face fewer health risks such as skin infections or HIV transmission.
Heroin use during pregnancy can have serious ramifications. It can cause premature separation of the placenta from the uterus, an underweight or premature baby, or stillbirth. Later in life, children exposed to heroin in utero are more likely to demonstrate inattention and cognitive impairment, and to display disruptive behavior. Medication-assisted treatment with methadone may reduce these outcomes, Abel says.
Two months have passed since Amanda sat at the needle exchange and first told me her story.
Today, Amanda is seven months pregnant. She’s ready to attend a methadone clinic, but without help she’s not sure she’ll actually go. Everyday things — like fighting with Twin or lacking a ride when he borrows her car — seem to prevent her from getting to the clinic. After waiting for hours, a clinic staffer calls her in and gives her the methadone—a cherry-flavored liquid that she drinks in front of them. She will have to come to the clinic every day to dose because she’s not allowed to bring the drug home.
A couple weeks later, Amanda is still using heroin and meth while continuing her methadone treatment. Her feet are swollen and tender, and the last time a nurse checked her blood pressure, it was high. The next day, she checks her blood pressure at a pharmacy and it is still high. She’s seeing stars. Then, she starts bleeding. She says she’s terrified that something is wrong with the baby but she’s even more afraid to go to a doctor because she worries that they’ll induce her, and she’ll wind up giving birth while she’s still using.
In a beige building downtown, a couple days later, Amanda signs into a health clinic. When called in, a doctor examines her and says the bleeding is likely the placenta separating from the uterine wall. The separation is not always life threatening for the baby, but it’s something doctors will need to monitor. The doctor tells her she’ll need to come in to the clinic twice a week. That’s a tall order since Amanda already struggles to get to her regular, less frequent appointments.
Amanda goes into labor at eight and a half months pregnant. She tells the doctors at the hospital that she’s been using heroin and meth, and they put her in the high-risk wing of the OB-GYN building. Late in the evening, she gives birth to a baby girl, whom she names Maci. The nurse places Maci on a scale to measure and weigh her. She’s five pounds, eight ounces. Amanda had agreed earlier to get an IUD inserted, so the nurses leave the baby on the scale while they perform the procedure. Afterward, Amanda holds Maci and rocks her. Amanda is so tired that she keeps falling asleep. She is transported upstairs to her hospital room and Maci is brought to the NICU, the neonatal intensive-care unit, where she’ll be watched for signs of withdrawal.
Three days later, a social worker visits Amanda at the hospital. She says there’s been a report of alleged neglect related to Amanda’s drug use. The social worker tells Amanda about the services available to her. Amanda cries and tells the social worker that she’s ready to turn her life around. She wants to enter rehab as soon as possible, hopefully a program that allows children to be placed with their mothers. The social worker nods. She has scheduled a meeting with CPS in a couple of days. Amanda, Twin, Amanda’s mother, and Amanda’s sister will be there.
Maci is having symptoms of withdrawal — shaking and spitting up. The hospital starts giving her methadone. This will help wean her off the drugs already in her system, but the treatment requires Maci to stay in the hospital even after Amanda is discharged. Following the CPS meeting, Amanda’s voice trembles as she relays the conversations. The social workers have serious concerns about her drug use and lack of stable housing. She has to go to family court and the judge will decide what will happen.
In family court, Twin tells me that the judge has ordered Maci to be placed in foster care with Amanda’s cousin. If Amanda wants custody, she will have to prove to the court that she’s confronted her drug use and housing issues, and is ready to be a parent again. Amanda is granted one-hour supervised visits with Maci twice a week.
When Maci is one week old, Amanda loses her motel room. She and Twin sleep in her car for a week. Amanda is still bleeding from the birth and she’s started lactating. A week later, she’s staying in another motel. She’s still using, and shoots up in the bathroom.
When Maci is two months old, Amanda plans to visit her. She hasn’t seen Maci since leaving the hospital. At her motel, she prepares: She hasn’t had any heroin that day and feels sick. “I definitely don’t want to go sick to see Maci ‘cause it’s horrible,” she says. “I won’t enjoy my visit with her.” She goes to her heroin dealer — who works out of a worn gray building downtown — and shoots up back in her motel room.
Amanda says she wants to go into a rehab program but is waiting for a drug evaluation from CPS. Once they determine what kind of program will be best for her, they will cover the bill. The visit with Maci takes place in a CPS office, with a living-room style space designed for these types of interactions: It has a couch, toys, and a side table. A social worker supervises Amanda and Twin’s visit. Maci cries a lot, maybe because she’s not used to either of them.
When Maci is four months old, Amanda and Twin get in a fight and the state issues a restraining order against Twin so that he can no longer see Amanda. Soon after, he’s arrested for procuring prostitutes. Two weeks after that, Amanda is evaluated by CPS and chooses to go into rehab at a residential Christian facility in Fresno that serves homeless and at-risk populations. It’s a 12-to-18-month program. Amanda says she’s really ready for rehab and to get out of what she calls “this lifestyle” — the drugs, the prostitution, her tumultuous relationship with Twin.
CPS previously told Amanda that if she can demonstrate that she has the mental and physical resources to be a stable parent for Maci, she has a chance of getting her daughter back. She knows it will be the hardest work of her life.