It's implied that Katie's mother, Sarah Fisher, killed Katie's child. Her mother couldn't bear to lose another child (one daughter had drowned, son had left the Amish community, and she had three miscarriages) and knew that her daughter would not be allowed to stay if she had the child. She hands Ellie Hathaway the scissors and twine used to cut and tie the umbilical cord and the book ends with Ellie hugging Sarah goodbye before walking out to Coop's car to start her new life.
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