ST. LOUIS - Patient safety at Missouri’s only abortion clinic is the point of contention at a state administrative hearing that will decide if the clinic can remain open.

Opening statements and testimony began Monday before a commissioner with the Missouri Administrative Hearing Commission. At issue is the state health department’s effort to revoke the license for Planned Parenthood’s clinic in St. Louis.

The state has said that part of the reason it is seeking to remove the license is a series of “failed abortions.” Assistant Attorney General John Sauer outlined details of those cases. In one, he said, a woman had to undergo up to five procedures over four days to complete the abortion. In another, a woman bled heavily after doctors failed to recognize a condition that put her at higher than normal risk.

Sauer cited a third incident where a woman had an abortion but later had to return for a second one because the doctor missed that she was pregnant with twins.

Donna Harrison, executive director of the American Association of Pro-Life Obstetricians and Gynecologists, was called as an expert witness by the state and reviewed the records. She said there was no indication that adequate follow-up exams were done on the patient.

“There is a much higher risk of infection” if fetal parts remain in a woman’s uterus after an abortion, Harrison said.

But Planned Parenthood’s attorney, Chuck Hatfield, played a video deposition of William Koebel, director of the section of the health department responsible for abortion clinic licensing, who was asked if the facility was deemed unsafe. “Not that I recall,” Koebel said.

Hatfield said that after a March inspection, the health department “moved the goal line” in an effort to take away the clinic’s license.

On Monday Koebel said that an inspection on March 11-13 discovered that no complication reports had been filed for a woman who had to undergo multiple procedures before her abortion was complete.

That incident prompted Koebel to request records of all incidents of women who had to undergo multiple abortion procedures. Four women were found. Details of the fourth were not outlined Monday.

Planned Parenthood officials said at the hearing that the state cherry-picked four difficult cases out of thousands of successful abortions.

Missouri would become the first state since 1974, the year after the Supreme Court’s Roe v. Wade decision, without a functioning abortion clinic if the license revocation is allowed. The battle also comes as abortion rights supporters raise concerns that conservative-led states, including Missouri, are attempting to end abortion through tough new laws and tighter regulation.

Several dozen observers filed the administrative hearing room at a state building in downtown St. Louis, the vast majority of them wearing pink T-shirts to show support for Planned Parenthood. Heightened security was outside amid concerns about possible protests. Planned Parenthood supporters unfurled a large abortion rights banner along a parking garage.

Commissioner Sreenivasa Rao Dandamudi is presiding over the hearing, which is expected to last five days. A commission official said that in his role, Dandamudi “acts as an independent trial judge.” A ruling isn’t expected until February at the earliest.

The health department has sought to interview physicians involved in those abortions, including medical residents who no longer work there. Planned Parenthood has said it can’t force them to talk and that the state’s concerns were addressed long ago. Attorneys for the health department wrote in legal filings to the commission that physicians’ refusal to talk “presents the final, critical obstacle.”

Missouri is among several states to pass new restrictions on abortions in the hope that the increasingly conservative U.S. Supreme Court will eventually overturn Roe v. Wade. Republican Gov. Mike Parson signed legislation in May banning abortions at or beyond eight weeks of pregnancy, with exceptions for medical emergencies but not for rape or incest.

A federal judge in August temporarily blocked implementation of the law until the legal challenge plays out in court, which could take several months.

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While the Missouri case unfolded, Planned Parenthood quietly built a new abortion clinic in Illinois, just across the Mississippi River from St. Louis. The 18,000-square-foot (1,700-square-meter) clinic in Fairview Heights, 12 miles (19 kilometres) east of St. Louis, opened Wednesday, in part to meet the demand for abortions from Missouri residents.

Missouri women have been increasingly getting abortions at the Hope Clinic for Women in Granite City, Illinois, another St. Louis suburb. Deputy Director Alison Dreith said 58% of the abortions performed at the Hope Clinic through August of this year involved Missouri women, compared with 37% involving Illinois women.

Another abortion clinic sits in Overland Park, Kansas, a Kansas City suburb. The clinic is 2 miles (3 kilometres) from the state line. Information from the state of Kansas shows about 3,300 of the 7,000 abortions performed there last year involved Missouri residents.