Jamie Chung for TIME

Correction Appended: January 3, 2012

It's 8 a.m. on a Wednesday, and Tammi Kromenaker is on the phone, trying to untangle an insurance snafu.

After 15 minutes of arguing with a billing operator, the director of the Red River Women's Clinic in Fargo, N.D., begins preparing for the patients who will soon arrive. Staff members trickle in. One puts a DVD of old sitcoms on the waiting-room television. Another straightens a pile of magazines. Someone brews a pot of coffee. By 10 a.m., the clinic is bustling with patients. Before the day is over, 18 women will undergo surgical abortions at Red River. Four others will receive abortion-inducing medication.

Kromenaker, a social worker, was born in January 1972, one year before the Supreme Court decided Roe v. Wade. She has spent her entire adult life providing abortion services and is among hundreds of clinic directors across the U.S. navigating an ever increasing number of state-imposed abortion regulations. At Red River, the only abortion clinic in North Dakota, a woman must wait 24 hours between scheduling an appointment and arriving at the facility. Once there, she must undergo a counseling, verification and testing process that lasts up to five hours. If she is a minor, she must notify her parents; get permission from one or both, depending on who has custody; or get approval from a judge. Like Medicaid programs in some 30 other states, North Dakota's does not cover abortion services except in instances of rape or incest or to protect the life of the mother.

In the past two decades, laws like the ones that govern appointments at Red River have been passed with regularity as pro-life state legislators have redrawn the boundaries of legal abortion in the U.S. In 2011, 92 abortion-regulating provisions--a record number--passed in 24 states after Republicans gained new and larger majorities in 2010 in many legislatures across the country. These laws make it harder every year to exercise a right heralded as a crowning achievement of the 20th century women's movement. In addition to North Dakota, three other states--South Dakota, Mississippi and Arkansas--have just one surgical-abortion clinic in operation. The number of abortion providers nationwide shrank from 2,908 in 1982 to 1,793 in 2008, the latest year for which data is available. Getting an abortion in America is, in some places, harder today than at any point since it became a constitutionally protected right 40 years ago this month.

It might seem as though recent electoral victories by Barack Obama and congressional Democrats set the stage for a reversal of this trend. The President's campaign mobilized Democratic voters and women around the issue of reproductive rights--an effort that produced, according to some exit polls, the widest gender voting gap in history. But while the right to have an abortion is federal law, exactly who can access the service and under what circumstances is the purview of states. And at the state level, abortion-rights activists are unequivocally losing.