1. When Elizabeth first learns about the little red book from her mother, did she respond appropriately? How might we respond differently, many decades later? How would we respond in ways similar to Elizabeth's mother and grandmother - that this was simply part of what it meant to be a midwife?

2. Elizabeth often seems to be caught in the middle of the people she loves - between her mother and grandmother, between Alvin and Ivy, and later Alvin and Lauren. How does this role of "in between" develop her as a character? Did she seem to have more choices or less, by seeing both sides?

3. Elizabeth comes from a long line of midwives. What role did the multi-generational aspect of the novel play? Was the knowledge and understanding of history a beneficial aspect of Elizabeth's life, or something that caused her more burdens?

4. The friendship between Elizabeth and Ivy would seem a very strange one. Did you feel that it was genuine on both sides? Given her mother's disapproval at the beginning, do you think this friendship was something she shared with her mother, or something she kept to herself?

5. Although Elizabeth has many chances to leave Kettle Valley in the novel, she never travels more than a short distance from her home. How does this affect her life and the choices that she makes? What emotions do you think were the ones that kept her from making the decisions to leave?

6. Many family secrets are told in this novel. What is the significance of these stories? Did you see them as gossip or oral history? Is there a difference between the two? Why do you think that Elizabeth is telling us her own story?

7. When Elizabeth learns that she is unable to have children, she is naturally devastated. How else did it change the way she saw herself and her relationship to those around her? Was it important that this knowledge came in the middle of the book?

8. What, if anything, do the men in Elizabeth's life have in common with each other? What was it that attracted her to them, and why did each relationship seem to end so sadly? Do you think that Elizabeth would have learned to love David Newland without Lauren?

9. Different forms of healing play a large role in this novel. Given that more women than ever are having babies with midwives or seeking alternative forms of healing, what do you think that medicine today has learned from the past? Did you find the notion of miracles a viable form of healing or not? What impact does one's spirituality have one one's health?

10. This novel does not have an epigraph at the beginning - a bit of poetic verse or a quotation from a book or speech. If you could give the book an epigraph, which one would you choose and why?

11. What kind of life do you imagine Elizabeth having after the book has ended? Do you believe she continues to practice some midwifery? What sort of mother is she likely to be to her children?