The state capital, Fargo, is home to the last facility offering terminations. And as laws tighten across America, the pro-life movement is starting to scent victory
By any standards Tammi Kromenaker does not have an easy job. She runs the Red River Women's Clinic in Fargo, North Dakota, which now offers the only remaining abortion service in the whole deeply conservative state. It is also under siege.
North Dakota's politicians have passed a series of new laws designed to put the clinic out of business. On many days, anti-abortion protesters stand outside the building's doors. Security is intense: doors are locked and there are cameras keeping an eye on those outside.
But Kromenaker, who knows she has to be careful in her daily life as she comes and goes in Fargo's shops and restaurants, has a simple explanation of why she sticks at it. Sitting in her clinic's spotless waiting room, she picked up a ring-bound notebook and read messages from desperate women who have turned to her at a time of unwanted pregnancy.
"I am getting teary," she confessed as she wiped an eye and scanned the book. "It is the women. You read this and you know; this is what keeps me coming back."
Not surprisingly, others on this most difficult of subjects have very different views. Indeed, despite Kromenaker's stalwart stance, a wave of anti-abortion legislation is sweeping through many parts of America, threatening to create something long desired by the "pro-life" lobby: a state with no abortion clinics at all. Even as other progressive causes in the US, such as gay marriage, appear to be on the march, the anti-abortion movement is growing in power and influence.
The pro-choice cause has hardly been helped by the shocking trial of a Philadelphia abortion doctor, Kermit Gosnell, who has been charged with murder, including snipping the spinal cords of babies born alive, as he carried out his procedures. All of America has been transfixed by the horror stories emerging from the case.
The jury in the trial has been locked in deliberations for more than two weeks, struggling to find a verdict. But, for many in the anti-abortion camp, the decision is already in: a huge public relations victory. "Gosnell may be an extreme case but these things are happening around the country," said Chris Dodson, executive director of the North Dakota Catholic Conference.
North Dakota is on the front line of the battle to recast US abortion laws. In March, the state legislature banned abortion beyond six weeks, at which point a heartbeat can be heard in the foetus, and carrying them out because of genetic abnormalities. It also enacted new rules forcing doctors who perform abortions in the state to have admitting privileges at local hospitals: something often difficult in states like North Dakota, where such doctors often come in from outside the area.
The new laws are set to come into effect on 1 August and Kromenaker has no doubt as to their intention or their potential impact. "If it happens, then we are out of business. We would cease to exist. That is their point and their goal," she said.
Of course, that would please many on the other side of the battle. Standing in a light rain outside the clinic in downtown Fargo, 64-year-old Ken Koehler looked back on almost 30 years of weekly protesting outside abortion clinics in the city. He held a placard with an adoption helpline phone number on it, and his moral stance on the issue was simple: what goes on inside is killing babies. "Two human lives enter the building, one comes out," he said.
Koehler is simply the face on the street of a powerful, well-funded and highly motivated movement of social conservatives that has been fighting abortion ever since it was legalised in the landmark supreme court decision of Roe v Wade in 1973. Dodson believes that they are winning the fight in America. "We should be able to do more," he said.
But they are already doing a lot across the country. In Arkansas, a state law was recently passed banning abortions after 12 weeks. The legislature in Kansas has voted for a bill defining life as beginning at fertilisation and banning sexual advice group Planned Parenthood from teaching sex education in schools. The bill also bans tax breaks for abortion providers.
The flow of new laws on the issue is relentless. The Guttmacher Institute, which tracks new legislation, reported that in the first three months of this year 14 states introduced laws that ban abortion even before the foetus becomes viable. Eight of those states passed bills defining "personhood" as beginning at conception.
Many other laws have been passed ostensibly to regulate clinics but in fact aimed at introducing arcane or difficult-to-comply-with rules – such as the regulations on doctors' admitting privileges. Now four states in the US – North Dakota, South Dakota, Wyoming and Mississippi – have just a single abortion clinic for their citizens.
Abortion providers view the backlash of recent years – spurred in part by the conservative sweep of the 2010 mid-term elections – with dread. They see the Gosnell case as an example of what happens with a clinic if it is not properly regulated by competent overseers: something that would happen a lot more if abortion was made impossible to get in any single state and back-alley abortions returned to America.
But in states such as North Dakota, which now faces a genuine threat to its last clinic, that prospect might become a reality. If it did, Kromenaker believes, it would be a disaster. Abortion would not stop, as its opponents would hope – instead, it would simply disappear into the dangerous shadows. It would also make abortion a class issue. In states with no clinics, only richer women would be able to afford to travel elsewhere to get the procedure done.
Meanwhile, poor women who did not want to be pregnant would have to go through with undesired births. "Whether or not you have children is a right for all women and it should not depend on where you live or how much you earn. We don't want North Dakotans to be second-class citizens," said Julie Rikelman, policy director at the Center for Reproductive Rights, a group that is providing legal help in fighting many of the new anti-abortion laws.
That fight is not going to be easy; nor, in the end, is it likely to go away. Abortion, with its emotive mix of sex and religion, is one of the most divisive issues in American politics; it is a feature of the national political landscape that will seemingly not erode away. In her clinic, Kromenaker shrugged her shoulders when asked if she thought it would ever be a non-issue in America. "No I don't think it will be," she said.
And in the meantime the fight to close – or to save – the Red River Women's Clinic will rage on, ebbing and flowing, and Kromenaker will continue to take courage from the words of support she gets from her patients, their families and supporters elsewhere.
"It helps with the isolation," she said. "I usually feel like I am walking around with a scarlet 'A' on my shirt: the abortion lady."