The children are the fruits of Ms. Elliott's life-saving labor: coaching pregnant women and new mothers to prevent their infants from dying.

Her triumphs aren't easily calculated, especially in a county where the infant mortality rate among African-Americans is four times higher than that of white children. Here, 21 black babies die before their first birthday for every 1,000 born alive - a rate three times the national average.

The numbers prove what Ms. Elliott and her team of five nurses in the Anne Arundel County Health Department already know: they have a lot more work to do.

But federal budget cuts sliced into the Healthy Start program Ms. Elliott supervises. In better years, losing the federal grant that paid for this program could have been a cut healed with money from the rest of the county health department's budget.

This is not a better year.

'There is no fat'

With dwindling state revenues and an equally austere budget outlook for the county government, Health Officer Frances B. Phillips is bracing for a situation "that would be catastrophic to this department."

"For downsizing, I have not begun to put together a plan," Ms. Phillips said. "We're talking about the wholesale elimination of … positions. There is no fat. There is no ability to shave (that much money)."

The $610,000 federal grant that funded Healthy Start also paid for a Medicaid ombudsman, a problem-solver who helped give the county's poorest people access to healthcare while navigating federal bureaucracy. Ms. Phillips said

that although the state has joined a lawsuit to challenge the way federal dollars are distributed, that money is gone for now.

"Unless there's a miracle, that's a definite," she said.

In the meantime, Ms. Phillips pledges to cobble together a diminished Healthy Start program. Even so, the nurses will not be able to visit 500 babies in their homes each year and address the 3,000 referrals, as they once did.

Moms who need help

Back when money wasn't so tight, Trinity's mom Cori Mackall was one of those referrals.

Trinity wasn't her first pregnancy. As a teen, Ms. Mackall miscarried. Now 23, she said she worried about Trinity, thinking her body just wasn't built for carrying children.

"For some reason, when I hit four months, my body just, like, rejects the baby," Ms. Mackall said.

On a doctor's visit early in her recent pregnancy, a health care worker took a look at Ms. Mackall's history, her social and financial situation, and quietly sent off a referral to the county health department. At first, Ms. Mackall was skeptical when the government called, asking if government nurses could help her through pregnancy.

"I was like, what are they trying to do, take my baby?" Ms. Mackall said. "I was so nervous."

Then she met Ms. Elliott. The way Ms. Mackall describes it, having a Healthy Start nurse is like having a modern-day Dr. Spock on speed-dial.

Ms. Mackall learned what she needed to eat during pregnancy, which doctors to see, which government agencies to visit and which paperwork to fill out to make sure the visits were paid for. She learned what warning signs to look for and where to go to have the medical procedure that ensured Trinity would survive.

Most importantly, she was encouraged to keep doing the right things - a new experience.

"Some people are really rude at the doctor's office when you're a first-time mom," Ms. Mackall said. "They act like you don't know what you're doing."

In Ms. Elliott's monthly visits after Trinity was born, she taught Ms. Mackall how to avoid SIDS, or sudden infant death syndrome, the best way to breast feed, and gave advice on which formulas to buy and how to get rid of that tricky rash on Trinity's stomach.

"You know everything about having babies until you have your own," Ms. Mackall said. "When you have your own, you're always second guessing yourself. … (Ms. Elliott) put my fears at ease."

Tallying heartbreak

Infant mortality, particularly among African-Americans, became a widespread concern in Anne Arundel in 2003, when statistics show the death rate rose to 23 babies for every 1,000 born alive.

The numbers show deaths are more prevalent in certain zip codes, concentrated in areas with low-income housing. But experts say the disparity between the death rates for black and white infants cuts across economic lines.

Joanne Hasman, a nurse-midwife at Special Beginnings in Arnold, is one of the members of the Anne Arundel Fetal Mortality Review Committee. Their heartbreaking task is this: tallying all the babies who died before their first birthday in Anne Arundel, then trying to figure out what went wrong.

"What we say a lot of times is: Did this mom have an event that could impact the pregnancy?" Ms. Hasman said. "Could it have been prevented?"

Often, the answer is yes. Mothers have housing troubles or social situations that cause high amounts of stress. They never accessed government programs, such as WIC, that could have helped deliver care.

Ms. Hasman regularly refers pregnant woman to the county's Healthy Start program for reasons that vary from the expectant mother's age, home, alcohol or drug use, income, marital status or inability to speak English.

"We really need to make sure that nobody falls through the cracks," Ms. Hasman said. "What Healthy Start does is gives the big picture to someone."

Beyond a task that many see as moral obligation, preventing infant mortality may save millions in taxpayer dollars. Premature birth is the leading cause of infant mortality, experts say, and in many cases premature births could be prevented with proper prenatal care.

Nationwide, premature babies and infants with low birth weight represent only 8 percent of births, but those babies ring up 47 percent of infant health costs at hospitals, according to a recent study published in the journal Pediatrics. These births cost 25 times more than an uncomplicated delivery. And Medicaid picks up the tab for the costly stays 42 percent of the time.

Many babies who do survive their first year of infancy frequently have disabilities that permanently link them to relying on government help.

"It's really setting them up for a lifetime of dependency on the social system," Ms. Phillips said.

For now, the fate of Healthy Start is unclear. The federal money is definitely gone, and the question is how much of the program can be reconstructed with county dollars.

Ms. Phillips said one thing remains certain: "We can not stop doing this work."

More to help

As soon as one baby and mother appear saved, another needs help. As Ms. Mackall was recovering from childbirth, her unborn nephew Markese began giving his mother trouble.

Taquana Gilmore, 20, had never been pregnant before, but a health care worker also referred her case to the health department and Ms. Elliott, whom she endearingly calls "Ms. Nancy," took her case.

When Ms. Gilmore started going into early labor at the beginning of her second trimester, Ms. Elliott convinced her to take bed rest and coaxed her through several more scares. Ms. Elliott also encouraged her to sit at the hospital for four hours waiting for the proper medical card so that her visits would be paid for.

At times, Ms. Elliott arranged rides to doctor's appointments.

Her apartment had little furniture, and certainly no crib. Ms. Elliott helped arrange for that, too.

"I'd be lost without Ms. Nancy," Ms. Gilmore said. "Anything I need, I can just call Ms. Nancy. After the baby was born I had the baby blues, you know. She came out right away and just gave me information and helped me out."

The word did not end once Ms. Mackall and Ms. Gilmore gave birth. Both women are now enrolled in college online, and Ms. Elliott helped them get financial aid, find grants and convinced Ms. Mackall the high-interest loan her college offered was a bad idea.

"Healthy Start is the best job I've ever had," Ms. Elliott said. "You get to hold other people's babies and boss them around. It's like being a mother in law."

Sometimes, it's also like being a mother.

"I follow girls who move all over the county from place to place to place," Ms. Elliott said. "They have never taken care of a baby. They don't know where they're going to live."

She visits one young woman in a Baltimore City homeless shelter a few times a week. "Just to be her mom, because she didn't have one," Ms. Elliott said. "Taquana and Cori didn't really need a mom. They already had them. They just needed a nurse to be an authority."