A hearing began Monday in Missouri over the fate of the state's lone abortion clinic, pitting Planned Parenthood against state officials who have refused to renew the clinic's license.

If health officials prevail, the hearing could result in Missouri becoming the only state in the country without a legal abortion clinic.

The licensing issue at the embattled Planned Parenthood of the St. Louis Region has created so much tension, Missouri officials asked St. Louis police for added security ahead of the start of the hearing, the Associated Press reported.

The hearing is expected to last for five days, although a ruling is not anticipated until at least February. It started Monday morning and is taking place at a state office building in downtown St. Louis, where a state arbiter is hearing arguments from both sides.

Health officials have characterized the clinic as failing to meet safety standards, while Planned Parenthood argues it has addressed all concerns.

On Monday, Assistant Attorney General John Sauer described cases of at least four patients who had "failed abortions" at the clinic, including one who needed up to five procedures to complete the abortion and another where clinicians did not realize a patient was pregnant with twins, resulting in the need for a second procedure to abort the second fetus.

Planned Parenthood attorney Chuck Hatfield, meanwhile, played a video deposition of a health department official who indicated there were no signs the clinic was unsafe.

The hearing is the latest development in a protracted legal battle. The Missouri Department of Health and Senior Services first decided not to renew the clinic's abortion license as of June 1 after an inspection in March found problems, including “at least one incident in which patient safety was gravely compromised,” “failed surgical abortions in which women remained pregnant,” and an alleged failure to obtain “informed consent.”

Planned Parenthood has said it addressed those issues months ago and argues the licensing battle is part of a broader anti-abortion push by the state's administration. In May, Missouri's Republican Gov. Mike Parson signed a bill banning abortions on or beyond the eighth week of pregnancy without exceptions in cases of rape or incest — one of the nation's most restrictive abortion bills.

Commissioner Sreenivasa Rao Dandamudi of the state's Administrative Hearing Commission is presiding over this week's hearing, and will act as an "independent trial judge," a commission official told the AP.

Planned Parenthood initially challenged the case in a St. Louis Circuit Court, where a judge sided with the clinic but kicked the legal battle to the Administrative Hearing Commission. The commission granted a stay that allowed the clinic to continue providing abortions until the hearing.

During the hearing, the state is calling three physician witnesses, which Planned Parenthood Advocates in Missouri referred to in a statement as "experts in anti-abortion advocacy dressed up as misleading medical jargon."

"The State is calling them because they support the coordinated effort to ban safe, legal abortion in Missouri," it said ahead of the hearing.

Missouri is one of six states that has only one abortion clinic. The other five states are Kentucky, Mississippi, North Dakota, South Dakota and West Virginia, according to the Guttmacher Institute, a research organization that supports abortion rights.

The licensing fight comes amid a slew of recent anti-abortion legislation across the country, including a near-total ban on abortions in Alabama. Organizations such as the American Civil Liberties Union are suing to block the bans, which they say are unconstitutional under the 1973 Supreme Court Roe v. Wade decision that federally legalized abortion.