The Valparaiso couple arrived at the hospital, the woman already in labor. A staff member wheeled her to the delivery unit, but it was too late. She gave birth in the wheelchair.
That was the first sign.
The newborn also had goosebumps. He shook violently. He let out a nonstop, high-pitched squeal.
He was addicted to heroin.
Nurses brought the baby to the neonatal intensive care unit, where he was put on morphine and phenobarbital to reduce his symptoms.
The medical staff told the parents they knew. The Department of Child Services later arrived to interview the new mom and dad.
Once the child's mother was ready to leave the hospital a few days later, the parents didn't get to take their baby with them. Instead, he went into the foster care system.
The mother and father only got to see their son periodically over the next three years. He was raised by his grandparents.
This story is all too common in Indiana, where babies are born dependent on opioids at a third more than the national average, according to data from the Indiana State Department of Health. Through the end of August, 15.7 percent of Indiana babies tested were addicted to opioids, compared to 10.7 percent nationwide.
In utero exposure to opioids puts infants at risk for social, emotional and intellectual delays, and can impair long-term immunity and protection against pathogens, medical experts say.
The Centers for Disease Control and Prevention has called neonatal abstinence syndrome an "often hidden consequence of the opioid epidemic." The incidence of the condition tripled between 1999 and 2013.
Despite the alarming numbers in Indiana, the state is one of the hardest places for pregnant women, or anyone for that matter, to access drug rehabilitation.
According to the Substance Abuse and Mental Health Services Administration, Indiana ranks 16th worst for the percentage of residents who needed substance abuse treatment in the past year but did not receive it.
When help is available, pregnant women often are afraid of letting medical professionals know about their addiction, for fear of having their babies taken away by the state.
"Many women who come in late in their pregnancy tend to not have had any prenatal care at all," said Peggy Payonk, program supervisor of acute addiction services at Merrillville-based Regional Mental Health Center, which gives priority to pregnant women for its residential drug treatment.
"Because they're fearful of what would happen if their OB finds out they're addicted to drugs, they can be seven to eight months pregnant and have had no prenatal care."
Indiana has the eighth-highest infant death rate in the nation, according to the most recent federal data. The state health department has identified lack of prenatal care as one of the leading risk factors. In addition, babies born dependent on drugs often have a low birth weight and respiratory distress, two of the top causes of infant mortality.
While Indiana doesn't punish maternal drug use as a crime, the state does consider it child abuse, putting mothers at risk of losing their newborns to foster care. Though not required by law, hospitals that birth a baby dependent on drugs generally report the incident to the Department of Child Services.
In Indiana, the number of children removed from the home for reasons including substance use jumped to 52.7 percent last year from 31.7 percent in 2013. The number of children in need of DCS services increased to 21,374 on the last day of the 2016 fiscal year from 13,684 on the final day of the 2013 fiscal year.
Meanwhile, neonatal abstinence syndrome is likely costing the state of Indiana a lot of money. According to the most recent CDC data from 2012, a healthy infant spent an average of 2.1 days in the hospital for a total cost of $3,500. A child born dependent on drugs, however, stayed an average of 16.9 days for a cost of $66,700.
In 2012, hospitals spent $1.5 billion caring for infants with neonatal abstinence syndrome; 80 percent of that was paid for by Medicaid, the state-based insurance program for the poor.
Since Oct. 1, 2015, Indiana Medicaid has spent $23.7 million to treat 1,616 babies born dependent on substances, according to the Family & Social Services Administration.
Effects go beyond infancy
Julie White, a clinical nurse educator at Porter Regional Hospital, described what it's like to witness newborns experiencing neonatal abstinence syndrome:
"The babies can have seizures. They get uncomfortable. They have tremors. Their bowel movements are loose and watery, so they have butt breakdowns.
"They get uncomfortable even when they eat. They have a tendency to throw up a lot, so they're hungry. It's kind of a vicious cycle getting them to eat, getting their food down. They're crying so hard they throw up.
"If you saw it, you would say, 'That baby, that's so sad, what's wrong?' "
The effects can be lasting.
Janice Wozniak, a Portage foster parent for more than four decades, has cared for numerous kids exposed to drugs in utero. She recalled one foster child she got as an infant whose mom used heroin during her pregnancy.
"By the time she was 15 months old, her behavior was so bizarre," Wozniak said. "We couldn't get her to stop laying in front of the dog dish and eating out of the dog dish and drinking out of the water. If she'd catch the bathroom door, she'd go in and dump her head in the toilet."
Wozniak knows of another local foster child born addicted to heroin who died in her sleep. She was 3 months old.
Nazareth Home in East Chicago was founded in the early 1990s to care for babies born with AIDS in Lake County. Now the foster home for medically challenged infants and toddlers mostly sees newborns dependent on drugs, mostly heroin.
"Babies being born drug-addicted is a huge problem and huge issue right now," said Jean Bowman, director of Nazareth Home. "I don't know what's going on that we have such a big crisis with the drugs."
Help could be on the way
Treatment does look to be expanding in Indiana. The federal government recently awarded the state $10.9 million to combat the opioid epidemic, 80 percent of which has to be spent on treatment.
The state Legislature also has allocated $5 million over each of the next two fiscal years for substance abuse treatment, prevention and enforcement, and passed more than a dozen bills during this year's session to fight the opioid crisis.
Two of them included pilot projects to expand treatment for pregnant women. One will test the best ways to pay for training for OB/GYN doctors to prescribe drugs such as buprenorphine for medication-assisted treatment, and to detect and treat neonatal-abstinence syndrome in babies and provide drug treatment to moms.
Another pilot project will set up residential drug treatment facilities for pregnant women and mothers of newborns in Indianapolis, Winchester and southern Indiana.
The latter program is modeled after the Fresh Start Recovery Center in the state capital, run by Volunteer Services of America Indiana. That center is believed to be the only in the state to treat pregnant women and new mothers, who are allowed to keep their newborns with them. The women also are taught parenting skills.
"If we can get pregnant women in, they can have babies while staying with us and can bring the babies after," said Shannon Schumacher, executive vice president of Volunteers of America Indiana. "Then we can have babies born without drugs in their system, avoiding all the NICU stays."
That program, however, has a waitlist of about nine to 10 months and roughly 140 women. The facility is expanding, though: It recently doubled its bed size, to 30 from 15, and is adding another 30 beds by the end of the year.
In addition, the managed care companies in charge of the state's Medicaid programs have joined with community mental health centers across the state on a pilot project, called MOMentum, to reduce neonatal abstinence syndrome. Eight facilities — including Valparaiso-based Porter-Starke Services and Swanson Center in LaPorte — have expanded their medication-assisted treatment offerings, including buprenorphine and methadone, and promised to get pregnant women and their partners into immediate treatment.
So far, though, all these programs are only being tested and available in certain parts of the state.
Data slow to come
The state Department of Health just recently started trying to determine the extent of the perinatal drug use in Indiana. The initial pilot project, in 2016, scored four hospitals, which had a neonatal abstinence syndrome rate of twice the national average. The screening initiative has since expanded to 26 hospitals across the state, including, in Northwest Indiana, the Franciscan health hospitals in Crown Point, Dyer, Hammond and Michigan City.
Only a handful of states mandate drug testing for new moms and infants; Indiana isn't one of them. That could change once the health department is done collecting its data.
"We will likely request universal screening based on the results," said Martha Allen, director of maternal and child health for the Indiana State Department of Health. "We want to increase our sample size first so we have confidence in the prevalence."
Hospitals now have to be equipped to treat neonatal abstinence syndrome. They first determine whether the baby is dependent on drugs and needs to be transferred to the NICU by using the Finnegan scoring system, which quantifies withdrawal symptoms.
Treatment is done by giving the baby opioids, such as morphine and methadone, eventually weaning them off, as well as fluids and high-calorie formula. NICU staff also provides comfort measures to the newborns.
"The aim is really to have a child be less stimulated," said Dr. Kemi Mascoll-Robertson, a neonatologist with Methodist Hospitals in Gary and Merrillville, which saw its cases of neonatal abstinence syndrome increase to 22 in 2016 from 14 the year before, with an average NICU stay of 31 days.
"You want to minimize light and sound: a quiet room, dim light. You also want to swaddle that infant, mimic how they feel inside the womb, gently rocking and cuddling them."
Community Health Network hospitals in Indianapolis has perhaps the most comprehensive approach to treating drug addiction in pregnant women. They are tested for drugs at their first prenatal appointment. Women who are addicted to opioids are prescribed Subutex, or buprenorphine, an opioid replacement medication (Suboxone generally isn't used because the ingredient naloxone is believed to be harmful to the fetus). A behavioral health specialist counsels the women on their addiction through their delivery. Care coordinators hook up the moms with social supports in the community.
Not all those services are reimbursable by insurance. "We're doing it because it's the right thing for the patient, who, in the long run, has better outcomes," said Donetta Gee-Weiler, vice president for women's and children's services for Community Health Network.
In the first year of the program, she said, the hospital system saw a $4 million savings and cut the number of pregnant women who tested positive for drugs at their first prenatal visit in half by the time of their delivery.
Child doing well
Five years later and having regained custody, the Valparaiso couple's child is healthy and entering kindergarten. He hasn't had any developmental delays as a result of his neonatal abstinence syndrome.
"I thank God," said his father, who would only speak to The Times if the newspaper didn't identify him. "He's advanced in every way. He's quick-witted, smart, asks questions."
The father said there simply aren't enough treatment options in Indiana for opioid-addicted people, pregnant or not. Even if there were, he said, the stigma surrounding addiction often prevents parents from telling their doctors the truth.
"We were guilty, ashamed, to reach out for help when she was pregnant," he said, "because of judgment, because we were afraid of getting our child taken away.
"It's a difficult thing to go into a doctor's office and say, 'I'm addicted to heroin.' For any rational person, that's what you should do to save the baby. But when there's that much guilt and shame, it makes it very hard.
"You're essentially asking somebody to say, 'You think I'm the biggest piece of s*** in the world, and you're going to talk about me when I get out of here and say what a horrible person I am — but can you help me?' "