ST. LOUIS (AP) — 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.

Assistant Attorney General John Sauer outlined cases of “failed abortions,” including one where a woman had to have up to five procedures to complete the abortion, and another where the doctor failed to recognize that a patient was pregnant with twins, requiring a second procedure to remove the second fetus.

Planned Parenthood attorney Chuck Hatfield played a video deposition of a health department official indicating the clinic is not unsafe.

Commissioner Sreenivasa Rao Dandamudi is presiding. 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 hearing at a downtown St. Louis state office building is expected to last five days. Missouri officials have asked St. Louis police for heightened security since the licensing issue has generated protests from those on both sides of the debate.

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.

Planned Parenthood has been battling the Missouri Department of Health and Senior Services for months to try to keep open its St. Louis clinic.

The state said concerns arose from inspections in March. Among the problems health department investigators cited were three “failed abortions” requiring additional surgeries and another that led to life-threatening complications for the mother.