Photo by Doug Koontz Home nurse Raini Blakeslee, left, checks on baby Lyric Campbell during her visit with mother, Nicole Franklin, as part of the Healthy Start program.

"How long should it take to come in?" asks her mother, Nicole Franklin.

Raini Blakeslee, a community health nurse, is there to answer. On her visit to Franklin's Madison Street apartment, she's also brought plastic covers for electrical outlets and a refrigerator latch, since Lyric will be walking soon, and a list of what Franklin can expect over the next several months as her daughter develops.

"She should be developing 'stranger fear,'" Blakeslee said, which is evident, as Lyric continually looks back at her mother when Blakeslee holds her.

Franklin is one of hundreds of county women who won't benefit from these home visits after June 30, and Blakeslee is one of six nurses at the Frederick County Health Department who won't have a job.

The federal Centers for Medicare and Medicaid Services has notified states they won't be providing reimbursement next year for a number of case management programs, including Healthy Start. Since the state won't be reimbursed, it can't fund the program.

The cuts come at a time when the number of low birth weight babies is climbing and the percentage of women getting prenatal care is dropping, both in the county and statewide.

A report released this week by Baltimore-based Advocates for Children and Youth shows that low birth weight babies, those born at 5.5 pounds or less, made up about 9 percent of all births statewide in 2006. Frederick County fared better, at 7.5 percent.

During the same year, about 77 percent of county women received early prenatal care, compared to 80 percent statewide. This percentage has dropped in the county every year since 2003.

Blakeslee and her colleagues have helped guide thousands of women through their pregnancies since the program started in 1992. But now, their first concern isn't their jobs. It's their clients.

"The women who are losing their jobs are asking 'what will happen to my girls?'" said Melinda Malott, the department's director of nursing.

In December 2006, 24-year-old Franklin and her boyfriend, Omar Campbell, came to Frederick from New York to visit Campbell's mother for Christmas.

Three days after they arrived, Franklin found out she was pregnant and called the health department for help.

The department referred her to a Frederick doctor and matched her up with Blakeslee for home visits. The two have met almost monthly since then, with Blakeslee explaining what Franklin can expect during each month of pregnancy, how she should take care of herself, and how her new daughter should be developing.

Franklin's was considered a high-risk pregnancy, since she'd had two previous miscarriages and a stillbirth. Her losses made her more sensitive to anything unusual, so she didn't hesitate to call Blakeslee when she had a question.

Without Blakeslee's help, her pregnancy would have been "confusing," Franklin said. "The doctor was helpful, but he didn't go into detail about bloodwork and other tests."

It's the same for all Healthy Start clients. When a woman comes to the health department for pregnancy help, she's immediately referred to a doctor in the area, and a Healthy Start nurse then ensures that she's attending her appointments, explains test results, and reinforces doctor recommendations. The nurse also becomes the woman's link to other services in the county.

"It's astounding how much people don't know about their bodies and about pregnancy," Blakeslee said. "Some need quick tips, and others need more help."

Something as simple as drinking enough water throughout the day escapes many women, especially those who have never been pregnant before, she said.

Nearly one-third of all county women who gave birth in 2006 had visits from Healthy Start nurses, said Amy Gunnarson, manager of the health department's Family Health and Wellness Program. The program is open to uninsured pregnant women who meet the income guidelines for the Maryland Children's Health Program.

Getting women into prenatal care early in their pregnancies reduces the number of babies born early or at a low weight, Gunnarson said.

In 2007, 83 percent of women in the Healthy Start program obtained prenatal care during the first trimester of pregnancy, compared to 44 percent of their peers who weren't in the program.

As a result, Healthy Start clients deliver prematurely less often than their peers, and in 2006, about 9 percent of women in the Healthy Start program had low birth-weight babies, compared to nearly 24 percent of women who had no prenatal care, according to department statistics.

Reducing premature and low-weight births saves money as well as lives, Gunnarson said. One premature birth and subsequent medical care can cost nearly $52,000, she said. In comparison, the Healthy Start program's total operating budget for fiscal year 2008 is $246,000, and the program needs $274,856 to continue services this year, according to department figures.

Through their visits, Healthy Start nurses can also pick up on other factors in the home, like substance abuse, child abuse, and mental health issues, Blakeslee said.

This is the first time the program's funding has been threatened, Malott said, and she's not sure how the department will continue to serve its Healthy Start clients. There's talk of reinventing the maternal child health program to continue to provide as many services as possible to pregnant women, but the home visits won't be available. Malott said the nurses are letting their clients know individually.

The health department has submitted several budget appeals to county commissioners, and it's unclear whether the department will ask for money specifically to fund Healthy Start.

"This is a tremendous hardship on families who will now not have the expertise of a nurse to improve their pregnancies," Malott said. "We need to be there for the moms so their babies are born healthy. It's our responsibility as a community."