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West Virginia hit the "F" category with a March of Dimes report card ranking states on the number of babies born prematurely.
The nonprofit group said West Virginia had a preterm-birth rate of 14.4 percent in 2005.
That's compared to 12.7 percent nationally, a D grade.
No state earned an A.
Maternal smoking and lack of health insurance have been cited as the two largest contributors to preterm births.
The March of Dimes report says about a third of women of child-bearing age in West Virginia smoke.
About 23 percent of those women have no health insurance.
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