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CHARLESTON, W.Va. -- Expectant mothers had various reasons for wanting to deliver their babies early.

They may have wanted their children born on a grandmother's birthday, or they may have become intolerant of the side effects of late pregnancy. And most thought it was safe to have a baby from 36 to 38 weeks gestation.

"It just had become so accepted," Nancy Tolliver said of the practice of inducing labor before 39 weeks.

And it wasn't always done at the convenience of the mother, said Tolliver, director of the West Virginia Perinatal Partnership.

She outlined this scenario. A pregnant woman has pains and thinks she is going into labor. She is taken to the hospital, a two-hour drive away. But she isn't; labor is still several hours off. Although it's best not to admit her, the doctor is afraid to send her home. She is admitted, but there's a time limit on how long she can stay. So her doctor decides to induce labor.

In 2008, nearly 36 percent of births in West Virginia were induced. Thirteen percent of births were induced before full term, and more than half of those were done for non-medical reasons.

That last statistic has been slashed by 60 percent in the past year -- since teams assembled in 14 West Virginia hospitals confronted the problem.

This year, 27 of 29 West Virginia hospitals are tackling a related issue: West Virginia has the fourth highest rate of cesarean births.

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It was a classic case of one thing leading to another.

It was 2006. The year before West Virginia had gotten its worst ranking on the well being of its children -- 47th out of 50 in the Kids Count national survey.

"West Virginia was facing a very high infant morality rate," said Tolliver. "We also had high rates of other things considered bad."

The Perinatal Partnership was funded by The Benedum Foundation to improve mother and baby wellbeing.

One of the first things the partnership undertook was a survey of 200 medical providers of maternity services. One problem uncovered was that pediatricians in rural areas were having trouble getting sick babies into any of the three hospitals in West Virginia that have neonatal intensive care units. Their beds were full, and babies were being sent out of state for care.

While looking into why infants were in intensive care units, Tolliver said they noticed "a very large increase in induction of labor prior to full term."

At the same time, Tolliver said national studies were showing that labor induced deliveries had "a lot of poor outcomes, especially for first time mothers. In West Virginia, there was more than a 30 percent chance they would end up having a cesarean. That's why we embarked on the project."

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The project is titled West Virginia Quality Collaborative for Eliminating Non-Medically Indicated Elective Preterm Deliveries Prior to 39 Weeks Gestation.

Organizations that developed the study were the West Virginia Health Care Authority, the West Virginia Health Improvement Institute, The West Virginia Perinatal Partnership and the West Virginia Chapter of the March of Dimes.

The 14 hospitals, which account for 70 percent of all births in the state, were Raleigh General, St. Joseph's in Buckhannon, CAMC, Thomas Memorial, Cabell Huntington, St. Mary's, Greenbrier Valley Medical Center, Monongalia Health System, West Virginia University Hospital, Camden-Clark, Princeton Hospital, Ohio, Valley Medical Center, Reynolds Memorial, and Weirton Medical Center.

Each hospital assembled teams representing administration, doctors and nurses to develop protocol and policies on labor inductions.

"There was a mixture of policies and procedures," Tolliver said. "Some adopted 'no exceptions' to labor induction for medical reasons only."

Some hospitals require a second doctor to agree that the procedure is medically needed. In other hospitals, Tolliver said, a labor hall nurse must make sure all procedures are followed before starting the steps to induce labor.

"The rate of elective inductions prior to 39 weeks declined 60.2 percent from 9.3 percent in 2008 to 3.7 percent in 2009," said the final report, released earlier this year. The decline has been maintained.

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"Here's the problem," Tolliver said. "A medical procedure is introduced and it takes a number of years before you start seeing the pros and cons."

In the nearly two decades from 1990 to 2008, the rate of labor inductions nationally increased 140 percent.

Then about seven or eight years ago, Tolliver said, more research was pointing out the risk factors if babies were born too early. "They have breathing difficulties, an inability to suck properly," she said, adding that more has been learned about development of the brain.

Information distributed by the March of Dimes says, "A baby's brain at 35 weeks weighs only two-thirds of what it will weigh at 40 weeks."

Still another problem with labor inductions is they don't always work, resulting in many more cesarean sections, said Tolliver.

"The majority of C-sections are first-time mothers," she said. "The babies do have problems more often than not. The mothers may develop adhesions or hemorrhaging. They may have problems with subsequent pregnancies.... Once a woman has had a C-section, it's very hard to go back to a vaginal birth."

On Friday, an introductory meeting on the second phase of the collaborative will be held at Embassy Suites.

Dr. David Lagrew will give a presentation on a similar project undertaken in California. "They reduced C-sections almost overnight," Tolliver said.

She said the issue is of such importance now because it's anticipated that health insurance coverage will not pay for a lot of elective procedures that don't have good outcomes.

A future study will look into the economic impact of reducing cesareans and labor inductions.

According to the March of Dimes, "C-sections are the Number 1 most common operative procedure done."

Another statistic cited: "Cost for a preterm birth is 15 times higher than for a healthy birth."

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Dr. Robert Nerhood and Dr. Michael Stiteley served on the first collaborative study.

The physicians taking part in the second phase, titled West Virginia First Baby Initiative, are Dr. Luis Bracero and Dr. William Holls, both maternal fetal medicine specialist, and Dr. David Jude, an obstetrician and gynecologist.

The Benedum Foundation was the major sponsor for the Perinatal Partnership for its first five years. On July 1, the state began funding the partnership. The West Virginia Health Care Authority is funding the First Baby Initiative.