Dr. David Henry and his wife, Norah, are expecting the birth of their baby. A blizzard hits their hometown in Kentucky, and then Norah suddenly goes into labor, forcing David to deliver his child in his personal office not far from their home. His nurse, Caroline Gill, meets him there an assists with the delivery.
Norah delivers a healthy baby boy, but David realizes she is about to deliver another child. She delivers a baby girl and then goes unconscious due to the anthesia. David and Caroline recognize the signs of down syndrome on his new daughter. David's sister died at a young age from heart disease, so David did not want to put this strain on his wife, son, and himself. He gives the baby to the nurse, Caroline Gill, and instructs her to take the infant to an institution outside of town. When Norah wakes up, David tells her the baby died shortly after birth and was taken away. The novel breaks into multiple stories: David's story, Norah's story, and Caroline's story.
Caroline takes the baby girl, Phoebe, to the institution but quickly realizes she cannot leave the child here. She decides to care for Phoebe herself. Caught in the snowstorm with a dead car, Al Simpson comes to her and Phoebe's rescue.
Norah struggles with accepting the death of her daughter as she tends to her son, Paul. She was told by her husband that the infant was stillborn and taken away to be buried.
David learns Caroline is keeping Phoebe for herself and begs her to give the child away. She refuses, he gives her money, she moves away and no one knows where she goes. They go to Pittsburgh.
The loss of their daughter makes it difficult for Norah and David to connect. They move to a new home with the intent to have a fresh start, but it does not have the desired effect. Norah wants to have another child but David refuses.
Caroline begins working for a man named Leo and his daughter. She and Phoebe live in his home. She claims Phoebe to be her own daughter and says she ran away from the father because he did not want to care for Phoebe. She and Al reconnect and begin a romantic relationship.
David and Caroline exchange letters, pictures, and cash. Caroline fears he will try to find her location but he never makes an attempt.
Phoebe and Paul are now 6 years old.
David is dedicated to photography and spends most of his time in his darkroom. Here he has a lockbox where he keeps the letters and pictures related to Phoebe hidden. Norah is a heavy drinker and starts to act out at times with her sister. She is extremely protective over her son. During a party, Paul falls and breaks his arm. It leads Norah and David to argue. The relationship between the two is more strained than it was 5 years earlier.
Caroline and Phoebe are still in Pittsburgh. Phoebe is healthy and happy. Caroline works with the Upside Down Society to fight for equal education rights for kids with down syndrome. Al has proposed to Caroline twice but she declined both times. When Phoebe is taken to the hospital for a bee sting, Al and the nurse have an altercation when the nurse insists she is less deserving of medical attention due to her condition. This display of love for Phoebe prompts Caroline to accept his marriage proposal.
Phoebe and Paul are 13 years old.
David and Norah live nearly completely separate lives. Paul is a guitarist and aspires to go to Juilliard, but David is unsupportive. Norah is a successful travel agent and takes her family on many vacations. The Henry family goes to Aruba where Norah invests in an affair with Howard. He is married with children who did not accompany him. This is not Norah's first affair. Paul and David are aware of the affair, but David blames himself for it.
Caroline and Al have been married for 5 years. Phoebe is still healthy and happy. David sends a letter asking to see Phoebe. Caroline stops responding in fear that he wants to take Phoebe or may hurt her unintentionally.
Paul and Phoebe are now 25 years old.
Norah and David are divorced. Paul was accepted to Juilliard. He is in France studying music and traveling. For some time now he has been contemplating telling his family about Phoebe but can never find the right words. Norah is engaged to another man and still lives in the home she lived with her son and ex-husband. While on a run, David has a heart attack and dies. Norah is unable to reach Paul to tell him about his father's death and funeral.
Caroline, Al, and Phoebe live happily. Phoebe has a boyfriend, Robert. She wants to live on her own but Caroline is too afraid to let Phoebe be on her own.
Norah begins to go through David's darkroom with the intent to move soon. She and her fiancé are getting married soon and moving to France. Caroline visits Norah and tells her about Phoebe. Norah and Paul go to visit her and build a relationship. Both of Norah's children stand with her at her wedding and plan to visit her while in France.