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Esta tese consiste em uma análise da formação em obstetrícia durante a graduação em medicina, baseada em pesquisa etnográfica realizada em duas escolas conceituadas. Objetivou-se estudar o modo como se articulam a competência técnica e científica e o cuidado ou relação com a paciente no ensino teórico e prático da assistência ao parto. As técnicas utilizadas na coleta de dados foram: observação participante, entrevistas semi-estruturadas e, de modo complementar, a análise de livros-texto e protocolos assistenciais. O trabalho abrangeu uma caracterização das propostas curriculares e um exame da experiência dos alunos quanto ao ensino teórico e prático, incluindo sua supervisão nas diversas atividades assistenciais. Ênfase maior recai sobre o desenvolvimento de conhecimentos científicos na formação. Mesmo no internato ênfase é colocada na aprendizagem da construção e encenação de narrativas clínicas, privilegiando-se a transmissão oral do conhecimento e a memória em relação ao registro escrito e à consulta ao prontuário das pacientes. Pautado em parte por assim chamadas concepções \"clássicas\", que sustentam uma visão patológica da fisiologia do parto, o exercício da prática envolve condutas que têm sido questionadas a partir das evidencias científicas ou até abandonadas em outros contextos As decisões acerca das condutas ou tratamentos adotados não são compartilhadas com as mulheres atendidas que frequentemente não são consultadas ou sequer informadas à respeito. Por vezes juízos de valor também influenciam o julgamento clínico e a tomada de decisões médicas. Há poucos parâmetros para avaliar as atitudes dos alunos em sua interação com as pacientes. Nos serviços em que há maior interação entre alunos e pacientes, a supervisão é menor. Existem acordos informais entre os assistentes na divisão de plantões que se contrapõe aos organogramas formais dos serviços obstétricos vinculados as Faculdades de medicina pesquisadas. Esses acordos subordinam os objetivos institucionais da boa formação e assistência em obstetrícia aos interesses individuais e coletivos dos profissionais obstetras responsáveis pela supervisão do ensino. Componente do currículo oculto, esses acordos servem de modelo para outros envolvendo residentes e/ou alunos. Ao longo da formação dos estudantes de medicina, as interações entre os sujeitos em relação no exercício do ato médico contribuem de diversas maneiras para desqualificar a prática médica da obstetrícia como técnica moral-dependente. / This thesis consists of an analysis of obstetric training during medical school. It is based on ethnographic research undertaken at two acknowledged medical schools. The objective was to study how technical and scientific competence and care, that is, the relationship with the patient, are articulated in theoretical and practical training of birth assistance. The techniques employed in fieldwork were: participant observation, semi-structured interviews and, in a complementary form, the analysis of textbooks and assistance protocols. A characterization of the curriculum offered by the schools and an examination of students experience with respect to learning the theory and practice of obstetrics, including the supervision of the various activities involving obstetric assistance are discussed. Description and analysis of the scission between the development of technical and scientific competence in the educational process was undertaken. The implications of this scission for training in the practice of medicine as a moral dependent technique are discussed. Great emphasis is placed on the development of scientific knowledge during training. Even in the clinical years, emphasis is placed on learning to construct clinical narratives, placing priority on memory and the oral transmission of knowledge rather than written registration and consultation of patiente\'s charts. Learning and training is based in part on so-called \"classical\" concepts, which sustain a pathological approach to birthing. In training, this approach involves norms of conduct that have been questioned by scientific evidence and that have even been abandoned in other contexts. Obstetrical decisions involving conduct and training are not taken in conjunction with the women receiving assistance who frequently are not even consulted or informed of these decisions. Sometimes prejudices influence medical judgment and decision-making. There are few parameters to evaluate student attitudes in their interaction with patients. In the work stations where students interact more with patients there is less supervision. Informal arrangements between assistants with respect to rounds conflict with the formal schedules of the obstetric services associated to the medical schools where research was undertaken. These arrangements subordinate the institutional objectives of good medical practice and assistance to the individual and collective interests of the obstetricians responsible for supervising training. These arrangements are a component of the hidden curriculum and serve as a model for other arrangements involving residents and/or students. Throughout the obstetric training of medical students, interactions between the subjects involved in the medical act contribute in several ways to disqualify the medical practice of obstetrics as a morally-dependent technique.

Cette recherche est consacrée à l’instruction en Afrique de l’Est allemande (Deutsch-Ostafrika : DOA), devenue au lendemain de la Grande Guerre un mandat britannique, le Tanganyika Territory, au sein de la British East Africa (BEA). Ce changement aurait pu entraîner des ruptures dans la politique scolaire, en particulier à l’endroit des Africains qui constituaient la majorité de la population aux côtés des Arabo-Swahili, des Indiens et d’une minorité d’Européens. Or, une logique de laisser-faire a prévalu durant la domination britannique qui s’est exercée dans le cadre d’un indirect rule, avec des moyens insuffisants accordés à l’enseignement. La formation d’auxiliaires, d’une main-d’œuvre qualifiée et d’agents intermédiaires pour les besoins de la colonisation reste primordiale dans les objectifs de la scolarisation, comme au temps de la DOA. Et en situation coloniale, les Arabo-Swahili et les Indiens continuent de jouer un rôle déterminant. Mosaïque de sociétés et de langues, la question linguistique s’avère fondamentale dans les enjeux scolaires sur ce territoire. À ce propos, des débats et des tensions virent le jour entre les différents acteurs éducatifs. Néanmoins, le kiswahili demeura pendant toute la période coloniale et au-delà.Malgré les discours et les enquêtes en vue d’une amélioration et d’une adaptation de l’enseignement, l’instruction du plus grand nombre ne figure pas au programme des écoles gouvernementales, davantage attachées à la formation d’une élite, que ce soit dans la DOA ou au Tanganyika Territory. La prise en charge de ce volet de l’enseignement reste dévolue aux établissements confessionnels tenus par les missionnaires, dont certains étaient présents depuis les dernières décennies du XIXème siècle. Mais les missionnaires poursuivent comme objectif essentiel l’évangélisation. La Seconde Guerre mondiale marque cependant une rupture dans la politique scolaire. Les associations et partis nationalistes, principalement la Tanganyika African National Union (TANU), s’approprient la question de l’instruction, surtout celle des Africains, pour préparer l’accession à l’indépendance. Ce pays si divers trouvera son unité grâce au chemin parcouru, souvent sinueux, pour adopter une langue commune africaine, le kiswahili, généralisé à l’époque coloniale allemande et à un homme, Julius Nyerere, qui va faire de l’instruction une priorité nationale. / This research is devoted to education in German East Africa (Deutsch-Ostafrika : DOA), which became Tanganyika Territory as a part of the British East Africa (BEA) in the aftermath of the Great War. This transition could have resulted in a discontinuity of school policy, particularly with regard to Africans who formed the majority of the population alongside Arabo-Swahili, Indians and a minority of Europeans. Instead, a strategy of laissez-faire prevailed during the British rule, which was a style of Indirect Rule that allotted insufficient means to education. The educational priorities, like at the time of DOA, were rather to train auxiliaries, create a skilled workforce and reinforce the intermediaries for the purpose of colonization. But even in this colonial context, Arabo-Swahili and Indians continued to play a decisive role. As a mosaic of societies and languages, the question of language proved pivotal in the educational discussions of the territory. Debates and tensions thus emerged between various educational actors; and yet, the Kiswahili persisted throughout the entire colonial period and beyond.Despite speeches and investigations meant to improve and adapt the educational system, education for the majority was not part of the program of government schools. These schools were far more concerned with training an elite during the German and British colonial periods. Education for the minorities was provided by religious schools run by the missionaries, some of them having existed since the last decades of the 19th century. Missionaries pursued evangelism as their main objective. However, World War II marked a rupture in school policy. Nationalist associations and parties, mainly the Tanganyika African National Union (TANU), appropriated the issues of education, especially African education, to prepare for independence. This diverse country finally achieved unity thanks to two factors: one, the efforts to adopt a common African language, Kiswahili, which was generalized during the German colonial era, and two, a man named Julius Nyerere, who made education a national priority. / Die vorliegende Arbeit befasst sich mit der Schulausbildung in Deutsch-Ostafrika (DOA). Nach dem Ersten Weltkrieg wurde das Tanganyika Territory, unter britisches Mandat gestellt, als Teil des Verbundes des British East Africa (BEA). Diese Zäsur brachte Umbrüche in der Schulpolitik mit sich, insbesondere für die afrikanische Bevölkerung, welche die Mehrheit der Bevölkerung stellten, vor arabischen Swahili, Indern und der europäischen Minderheit. Dennoch war die Zeit der britischen Vorherrschaft, im Rahmen der indirect rule, von einer Logik des Laisser-faire geprägt, und für die Ausbildung standen nur unzureichende Mittel zur Verfügung. Auch in dieser Zeit, wie auch schon während der deutschen Kolonialisation, blieb die Ausbildung von Hilfspersonal, qualifizierten Arbeitskräften und mittleren Verwaltungs-beamten das vornehmliche Ziel der Schulbildung. Unter den britischen Kolonialherren spielten weiterhin die arabischen Swahili und Inder eine wichtige Rolle. In diesem Puzzle aus verschiedenen Gesellschaften und Sprachen auf diesem Territorium war hinsichtlich schulischer Belangen die Frage nach dem Erlernen der Sprachen von fundamentaler Bedeutung. Diesbezüglich kam es zu Auseinandersetzungen und Spannungen zwischen den verschiedenen Akteuren der schulischen Bildung. Trotzem blieb das Kiswahili während der gesamten Kolonialzeit und auch über diese Zeit hinaus die vorherrschende Sprache.Trotz vieler Reden und Studien im Hinblick auf die Verbesserung und Anpassung des Unterrichts, das Unterrichten der Hauptzahl der Bevölkerung war nicht Ziel von der Regierung eingerichteten Schulen, die vornehmlich der Ausbildung der Elite dienten, sowohl unter der deutschen Kolonialherrschaft, als unter britischem Mandat. Das Unterrichten der anderen Bevölkerungskreise wurde konfessionnell getragenen Schulen überlassen, die von Missionaren geleitet wurden, die teilweise seit dem ausgehenden 19. Jahrhundert auf dem Territorium anwesend gewesen sind. Deren Hauptziel war jedoch die Mission. Der Zweite Weltkrieg bringt dennoch eine Zäsur in der Schulpolitik mit sich. Vereinigungen und nationalistische Parteien, insbesondere die Tanganyika African National Union (TANU), machen sich die Frage der Schulbildung, insbesondere die der afrikanischen Bevölkerung, zu eigen, mit dem Ziel des Erlangens der Unabhängigkeit. Dieses sehr vielseitige Land wird seine Einheit in dem gemeinsam beschrittenen, verschlugenen Weg finden in der Wahl einer gemeinsamen afrikanischen Sprache, dem Kiswahili, das während der deutschen Kolonialzeit durchgesetzt wurde, und durch Julius Nyerere, der die Schulbildung zu einer Frage von nationaler Wichtigkeit machte.

Most couples eagerly anticipate the birth of their first child. However, the transition to parenthood is also associated with significant lifestyle changes and approximately 50% of couples report a moderate to severe decline in relationship satisfaction and quality. Low relationship satisfaction is associated with increased couple conflict, individual psychological distress, negative parent-child relationships and poor child outcomes. Despite our increasing knowledge of the factors that predict enhanced couple adjustment, few evidence-based programs are available to assist couples' adjustment to parenthood. In this first randomized controlled trial evaluating the effectiveness of a flexible delivery psycho-education program, entitled 'Couple CARE for Parents', 71 pregnant couples were assessed on self-report and observational measures of couple relationship and individual functioning and then randomized into either the Couple CARE for Parents program (n = 35) or a comparison program (n = 36). Couple CARE for Parents was a six unit program, comprising of an antenatal workshop, two home visits and three telephone support calls, and included skill-training in key relationship processes that are predictive of couple relationship quality, with the addition of parenting and baby care information. Among intervention couples the typical decline in female relationship satisfaction was prevented, with only 13% of intervention females reporting a decline in relationship satisfaction from pregnancy to 5 months postpartum, compared to 42% of females in the comparison program. Observed couple communication also improved as a result of the intervention, with Couple CARE for Parents couples showing reliably lower rates of negative speaker and listener skills at post-intervention relative to comparison couples. Couples were highly engaged in Couple CARE for Parents and there was a low drop out rate across the 7 month intervention period. These findings are promising and add to the early intervention studies showing positive effects of couple-focused psycho-education during the transition to parenthood by demonstrating that flexible delivery programs are feasible and attractive to couples. Providing cost-effective couple relationship education to expectant and new parent couples opens another window of opportunity for health professionals and governments to minimize the rates of relationship distress and divorce and their associated negative effects on individual, couple and family functioning.

Esta tese consiste em uma análise da formação em obstetrícia durante a graduação em medicina, baseada em pesquisa etnográfica realizada em duas escolas conceituadas. Objetivou-se estudar o modo como se articulam a competência técnica e científica e o cuidado ou relação com a paciente no ensino teórico e prático da assistência ao parto. As técnicas utilizadas na coleta de dados foram: observação participante, entrevistas semi-estruturadas e, de modo complementar, a análise de livros-texto e protocolos assistenciais. O trabalho abrangeu uma caracterização das propostas curriculares e um exame da experiência dos alunos quanto ao ensino teórico e prático, incluindo sua supervisão nas diversas atividades assistenciais. Ênfase maior recai sobre o desenvolvimento de conhecimentos científicos na formação. Mesmo no internato ênfase é colocada na aprendizagem da construção e encenação de narrativas clínicas, privilegiando-se a transmissão oral do conhecimento e a memória em relação ao registro escrito e à consulta ao prontuário das pacientes. Pautado em parte por assim chamadas concepções \"clássicas\", que sustentam uma visão patológica da fisiologia do parto, o exercício da prática envolve condutas que têm sido questionadas a partir das evidencias científicas ou até abandonadas em outros contextos As decisões acerca das condutas ou tratamentos adotados não são compartilhadas com as mulheres atendidas que frequentemente não são consultadas ou sequer informadas à respeito. Por vezes juízos de valor também influenciam o julgamento clínico e a tomada de decisões médicas. Há poucos parâmetros para avaliar as atitudes dos alunos em sua interação com as pacientes. Nos serviços em que há maior interação entre alunos e pacientes, a supervisão é menor. Existem acordos informais entre os assistentes na divisão de plantões que se contrapõe aos organogramas formais dos serviços obstétricos vinculados as Faculdades de medicina pesquisadas. Esses acordos subordinam os objetivos institucionais da boa formação e assistência em obstetrícia aos interesses individuais e coletivos dos profissionais obstetras responsáveis pela supervisão do ensino. Componente do currículo oculto, esses acordos servem de modelo para outros envolvendo residentes e/ou alunos. Ao longo da formação dos estudantes de medicina, as interações entre os sujeitos em relação no exercício do ato médico contribuem de diversas maneiras para desqualificar a prática médica da obstetrícia como técnica moral-dependente. / This thesis consists of an analysis of obstetric training during medical school. It is based on ethnographic research undertaken at two acknowledged medical schools. The objective was to study how technical and scientific competence and care, that is, the relationship with the patient, are articulated in theoretical and practical training of birth assistance. The techniques employed in fieldwork were: participant observation, semi-structured interviews and, in a complementary form, the analysis of textbooks and assistance protocols. A characterization of the curriculum offered by the schools and an examination of students experience with respect to learning the theory and practice of obstetrics, including the supervision of the various activities involving obstetric assistance are discussed. Description and analysis of the scission between the development of technical and scientific competence in the educational process was undertaken. The implications of this scission for training in the practice of medicine as a moral dependent technique are discussed. Great emphasis is placed on the development of scientific knowledge during training. Even in the clinical years, emphasis is placed on learning to construct clinical narratives, placing priority on memory and the oral transmission of knowledge rather than written registration and consultation of patiente\'s charts. Learning and training is based in part on so-called \"classical\" concepts, which sustain a pathological approach to birthing. In training, this approach involves norms of conduct that have been questioned by scientific evidence and that have even been abandoned in other contexts. Obstetrical decisions involving conduct and training are not taken in conjunction with the women receiving assistance who frequently are not even consulted or informed of these decisions. Sometimes prejudices influence medical judgment and decision-making. There are few parameters to evaluate student attitudes in their interaction with patients. In the work stations where students interact more with patients there is less supervision. Informal arrangements between assistants with respect to rounds conflict with the formal schedules of the obstetric services associated to the medical schools where research was undertaken. These arrangements subordinate the institutional objectives of good medical practice and assistance to the individual and collective interests of the obstetricians responsible for supervising training. These arrangements are a component of the hidden curriculum and serve as a model for other arrangements involving residents and/or students. Throughout the obstetric training of medical students, interactions between the subjects involved in the medical act contribute in several ways to disqualify the medical practice of obstetrics as a morally-dependent technique.