Objective: To describe common barriers faced by physicians initiating second trimester inpatient abortion services and strategies used to overcome them. Methods: Semi-structured in-depth interviews were conducted with physicians who initiated or attempted to initiate second trimester inpatient abortion services at US hospitals. Interviews explored participants’ motivation and processes for implementing services, logistics of program implementation, as well as barriers they encountered and how they overcame these barriers. Interviews were transcribed, coded, and analyzed to identify common themes. Results: A geographically diverse sample of 21 physicians were interviewed, 4 of whom were unsuccessful in initiating services. Service implementation efforts took place between 2001 and 2014. While specific barriers varied somewhat by geographic region and payor status for abortion, the most commonly cited were staff and institutional barriers, specifically nursing resistance/refusal, institutional policies and pushback from leadership. Anticipating barriers did not always predict being able to overcome them, though leadership support and generating buy-in were key facilitators to overcoming barriers. Other successful strategies included employing exceptional flexibility, working around the system or under the radar, and “killing them with kindness.” Participants voiced patience, determination, and resilience as key personal factors in successfully establishing services. Conclusions: Barriers to establishing inpatient second trimester surgical abortion services are similar across the nation. Anticipating these barriers is helpful but not always sufficient in overcoming them. Physicians who wish to establish these services should prepare for individual and institutional resistance, enlist leadership support early, and be prepared to employ flexible strategies to overcome unforeseen barriers.