The practice of quiltmaking—stitching layers of fabric and fiber into a textile sandwich—developed in antiquity. It is usually identified as women's work and pleasure. In America, quiltmaking was influenced by both the mass culture and local folk ways. West Virginia quilts are in many ways the same as quilts made by women of similar circumstances throughout the nation, dictated by fashion and fabric supply. Quiltmaking styles are rarely confined to political boundaries such as state lines, for popular culture and taste are national and regional in character.

Thus, antique quilts from the Mountain State are similar to others made throughout the Southern highlands. For example, West Virginia quilts share a feature with quilts made in other areas settled primarily by Scotch-Irish: a quilting pattern made by stitching rows of concentric arcs across the surface of a quilt, known as "the fans." In areas of German settlement, quilts more often have distinctive borders and use a variety of quilting motifs to distinguish construction components.

Still, our quiltmaking has its distinctive features. West Virginia quiltmakers retain old ways of doing things by hemming a quilt (folding the lining to the front for edge finish) rather than binding it, and by using the earlier pattern name "Dutch Girl" for an applique figure known elsewhere as "Sunbonnet Sue." Some quilts carry material evidence of the diversified farmstead, such as the use of hand-carded batts of homegrown wool as the insulating inner material. Quiltmakers in southern West Virginia may join their blocks in a zigzag manner, a setting known as "Fence Rail," uncommon elsewhere and possibly Welsh in origin.

In early days, before American cotton textile mills came into operation, fabric for quiltmaking was an expensive, imported commodity. The considerable amount of time and materials required to construct a quilt limited the practice mostly to the well-off. During the decades before the Civil War, prosperous quiltmakers with cultivated taste cut and stitched luxury fabrics from England and France into decorative finery for the bed. Western Virginia quilts from this era are similar to ones made in Maryland, Pennsylvania, Ohio, and eastern Virginia. Floral applique and repeating pieced blocks on a white background with consistent fabrics (instead of an assortment of sewing scraps) are typical.

After the Civil War, industrial development brought affordable cotton cloth and thread, and sometimes sewing machines, into the homes of working-class women. The "scrap" quilt made its appearance, displaying the wide variety of printed cotton fabrics now available. Pieced block patterns were marketed through newspapers and other periodicals during the late 19th century and throughout the 20th.

By the turn of the century, a confluence of factors in West Virginia led to the development of a distinctive quilt style, the utility crazy quilt. Crazy quilts were a national fad in the 1880s and the Gay Nineties; their eclectic look suited Victorian taste. Crazy quilts may be constructed with odd and random pieces of fabric, rather than the precisely cut shapes required for other patchwork. The ease of preparation might have appealed to West Virginia women with little or no previous quiltmaking experience, such as wives of immigrant laborers and rural women who had previously lacked exposure to the craft. In West Virginia, the crazy quilt flourished long after fading from the national scene, stitched from pieces of recycled garments, printed feed sacks, and polyester double knits.

In West Virginia, quiltmaking is celebrated with annual quilt shows around the state. Women's groups not uncommonly turn to quiltmaking as a way to raise money. The federal War on Poverty engendered a number of cooperatives devoted to quiltmaking, notably Mountain Artisans and Cabin Creek Quilts. Family quilts are preserved and cherished.