Thèse numérisée par la Direction des bibliothèques de l'Université de Montréal.

Pesquisa piloto de intervenção com dados prospectivos, grupo único de intervenção, cujo desfecho é a medida da dor de mulheres em trabalho de parto. Apresenta como objetivo discutir os efeitos da crioterapia no alívio da dor das parturientes. Como referencial teórico este trabalho apresentou o descrito por Soares e Low, onde se encontra que os mecanismos de ação do gelo para alívio da dor propiciam o decréscimo da transmissão das fibras de dor, a diminuição da excitabilidade nas terminações livres, a redução no metabolismo tecidual aumentando o limiar das fibras de dor e a liberação de endorfinas. Baseou-se ainda nos princípios da desmedicalização e do emprego de tecnologias não-invasivas de cuidado de enfermagem obstétrica conforme descritos por Vargens e Progianti. A pesquisa foi realizada no Centro Obstétrico do Hospital Municipal Maternidade Carmela Dutra, no Rio de Janeiro de abril a agosto de 2011. O gelo foi aplicado, utilizando-se para tal uma bolsa-cinta ajustável à região tóraco-lombar de 36 gestantes. A bolsa/cinta é descartável, de tecido TNT, com abertura na parte superior para introdução de gelo picado envolto em plástico. As aplicações se deram aos cinco centímetros de dilatação do colo uterino; e/ou aos sete centímetros de dilatação do colo uterino; e/ou aos nove centímetros de dilatação uterina, totalizando ao final das três aplicações um tempo de 60 minutos, que corresponde ao somatório de 20 minutos para cada uma. O gelo foi produzido em fôrma exclusiva para o projeto, em freezer da unidade. Os dados referentes à avaliação da dor foram coletados através de entrevista estruturada guiada por formulário previamente elaborado. Os resultados evidenciaram que a crioterapia produziu extinção ou alívio da dor quando aplicada na região tóraco-lombar das parturientes aos cinco, sete ou nove centímetros de dilatação do colo uterino, dando-lhes maiores condições de vivenciar o seu trabalho de parto; produziu um relaxamento geral e local (na região lombar) das parturientes; não interferiu na dinâmica uterina e, não causou dano ao binômio mãe-filho. Concluiu-se que a crioterapia, na forma como descrita no presente estudo, pode ser considerada uma tecnologia não-invasiva de cuidado de enfermagem obstétrica para alivio da dor no trabalho de parto. / This pilot intervention study, with prospective data and a single intervention group, the outcome of which was the pain measured in women in labour, was designed to discuss the pain relief effects of cryotherapy in childbirth. The theoretical framework for this study was as described by Soares & Low, in which the mechanisms of the pain-relief action of ice foster decreased pain fibre transmission, reduced free nerve ending excitability, reduced tissue metabolism, increased pain fibre threshold and release of endorphins. It also drew on the principles of de-medicalisation and non-invasive obstetric nursing techniques as described by Vargens & Progianti. The study was conducted at the Obstetrics Centre of the Carmela Dutra Municipal Maternity Hospital, in Rio de Janeiro, from April to August 2011. Ice was applied using an adjustable belt-bag to the lumbar/thoracic region of 36 expectant mothers. The disposable TNT fabric belt-bag has an opening at the top for introducing plastic-wrapped ground ice. Applications were given at five centimetres cervical dilation; and/or at seven centimetres cervical dilation; and/or at nine centimetres cervical dilation: to a total of three applications over a 60-minute timespan, corresponding to the sum of 20 minutes each. The ice was produced exclusively for the project in the units freezer. Pain assessment data were collected by structured interview guided by a previously prepared script. The results provided evidence that cryotherapy produced extinction or relief of pain when applied to the lumbar-thoracic region of women in labour at five, seven or nine centimetres cervical dilation, affording them better conditions in which to experience their labour; it produced relaxation (both overall and locally, in the lumbar-thoracic region) in the women in labour; and it neither interfered in the dynamics of the uterus nor caused harm to the mother and child. It was concluded that cryotherapy, as described in this study, can be considered a non-invasive obstetric nursing technology for pain relief in labour.

Notre laboratoire a développé une stratégie d'isolement de fragments d'anticorps recombinants à partir de primates non humains (Macaca fascicularis) immunisés, en utilisant la technologie des phages. Dans le cadre de cette thèse, une comparaison des séquences d'anticorps de macaques (Macaca Mulatta) et d'anticorps humains a toutefois montré que les anticorps des deux espèces présentent des différences qui rendent souhaitable une étape d'humanisation des anticorps de macaques. Cette stratégie a été utilisée dans le cadre du projet Européen AntiBotABE (www.antibotabe.com) et l'étape de criblage a été adaptée pour isoler des scFv neutralisant de façon croisée les toxines botuliques BoNT/B des sous-types B1 et B2, en utilisant séquentiellement l'holotoxine BoNT/B1 et un fragment recombinant représentant la région C-terminale de la chaîne lourde de BoNT/B2. Le meilleur scFv ciblant les régions C-terminales des chaînes lourdes de BoNT/B1 et BoNT/B2, B2-7, a montré une bonne capacité de neutralisation de BoNT/B1 et BoNT/B2 dans le test ex vivo de paralysie hémidiaphragmatique. Les régions charpentes du scFv B2-7 ont un pourcentage d'identité élevé (80 %) avec leurs homologues humains. Des scFv neutralisant BoNT/A1 en ciblant sa chaîne légère ont aussi été isolés, dont le scFv le plus efficace, 2H8, induit une diminution de 50% de l'activité endopeptidasique à une concentration correspondant à un rapport molaire 2H8/BoNT/A1 de 64000. Les régions charpentes de 2H8 ont également un pourcentage d'identité élevée (88%) avec leurs homologues humains. La versatilité de cette stratégie en fait un outil permettant l'isolement de nombreux autres fragments d'anticorps à visée thérapeutique. / Our laboratory has developed a strategy to isolate recombinant antibody fragments technology from immunized non human primates (Macaca fascicularis) by phage display. In the course of the present thesis, a comparison between macaque (Macaca mulatta) and human antibody sequences has demonstrated that antibodies of the two species are different. This difference makes the humanization of macaque antibodies desirable. The strategy was used in the framework of the European AntiBotABE project, and the screening was adapted to isolate antibody fragments cross neutralizing the B1 and B2 subtypes of botulinum B neurotoxin, by using sequentially the holotoxin BoNT/B1 and a recombinant fragment representing the C-terminal region of the heavy chain of BoNTB2. The best scFv targeting the C-terminal region of BoNT/B1 and BoNTB2 heavy chains, B2-7, demonstrated a high capacity to neutralize BoNT/B1 and BoNT/B2 in the ex vivo hemidiaphragmatic assay. A high identity (80%) between the framework regions of B2-7 and their human homologs was observed. ScFvs neutralizing BoNT/A1 by targeting its light chain were also isolated and among them, the scFv 2H8 induced a decrease of 50% in the endopeptidase activity at a concentration corresponding to a molar ratio of 2H8/BoNT/A1 of 64000. A high identity (88%) between the framework regions of 2H8 and their human homologs was also observed. Our strategy can be used to isolate other therapeutic antibody fragments.

Pesquisa piloto de intervenção com dados prospectivos, grupo único de intervenção, cujo desfecho é a medida da dor de mulheres em trabalho de parto. Apresenta como objetivo discutir os efeitos da crioterapia no alívio da dor das parturientes. Como referencial teórico este trabalho apresentou o descrito por Soares e Low, onde se encontra que os mecanismos de ação do gelo para alívio da dor propiciam o decréscimo da transmissão das fibras de dor, a diminuição da excitabilidade nas terminações livres, a redução no metabolismo tecidual aumentando o limiar das fibras de dor e a liberação de endorfinas. Baseou-se ainda nos princípios da desmedicalização e do emprego de tecnologias não-invasivas de cuidado de enfermagem obstétrica conforme descritos por Vargens e Progianti. A pesquisa foi realizada no Centro Obstétrico do Hospital Municipal Maternidade Carmela Dutra, no Rio de Janeiro de abril a agosto de 2011. O gelo foi aplicado, utilizando-se para tal uma bolsa-cinta ajustável à região tóraco-lombar de 36 gestantes. A bolsa/cinta é descartável, de tecido TNT, com abertura na parte superior para introdução de gelo picado envolto em plástico. As aplicações se deram aos cinco centímetros de dilatação do colo uterino; e/ou aos sete centímetros de dilatação do colo uterino; e/ou aos nove centímetros de dilatação uterina, totalizando ao final das três aplicações um tempo de 60 minutos, que corresponde ao somatório de 20 minutos para cada uma. O gelo foi produzido em fôrma exclusiva para o projeto, em freezer da unidade. Os dados referentes à avaliação da dor foram coletados através de entrevista estruturada guiada por formulário previamente elaborado. Os resultados evidenciaram que a crioterapia produziu extinção ou alívio da dor quando aplicada na região tóraco-lombar das parturientes aos cinco, sete ou nove centímetros de dilatação do colo uterino, dando-lhes maiores condições de vivenciar o seu trabalho de parto; produziu um relaxamento geral e local (na região lombar) das parturientes; não interferiu na dinâmica uterina e, não causou dano ao binômio mãe-filho. Concluiu-se que a crioterapia, na forma como descrita no presente estudo, pode ser considerada uma tecnologia não-invasiva de cuidado de enfermagem obstétrica para alivio da dor no trabalho de parto. / This pilot intervention study, with prospective data and a single intervention group, the outcome of which was the pain measured in women in labour, was designed to discuss the pain relief effects of cryotherapy in childbirth. The theoretical framework for this study was as described by Soares & Low, in which the mechanisms of the pain-relief action of ice foster decreased pain fibre transmission, reduced free nerve ending excitability, reduced tissue metabolism, increased pain fibre threshold and release of endorphins. It also drew on the principles of de-medicalisation and non-invasive obstetric nursing techniques as described by Vargens & Progianti. The study was conducted at the Obstetrics Centre of the Carmela Dutra Municipal Maternity Hospital, in Rio de Janeiro, from April to August 2011. Ice was applied using an adjustable belt-bag to the lumbar/thoracic region of 36 expectant mothers. The disposable TNT fabric belt-bag has an opening at the top for introducing plastic-wrapped ground ice. Applications were given at five centimetres cervical dilation; and/or at seven centimetres cervical dilation; and/or at nine centimetres cervical dilation: to a total of three applications over a 60-minute timespan, corresponding to the sum of 20 minutes each. The ice was produced exclusively for the project in the units freezer. Pain assessment data were collected by structured interview guided by a previously prepared script. The results provided evidence that cryotherapy produced extinction or relief of pain when applied to the lumbar-thoracic region of women in labour at five, seven or nine centimetres cervical dilation, affording them better conditions in which to experience their labour; it produced relaxation (both overall and locally, in the lumbar-thoracic region) in the women in labour; and it neither interfered in the dynamics of the uterus nor caused harm to the mother and child. It was concluded that cryotherapy, as described in this study, can be considered a non-invasive obstetric nursing technology for pain relief in labour.

Les anticorps recombinants représentent une approche prometteuse pour améliorer le traitement et la prophylaxie des maladies causées par les armes biologiques. De tels anticorps peuvent être isolés à partir de primates non humains, dont l'immunisation est plus facile à concevoir et à réaliser que l'immunisation d'humains. Des chimpanzés (Pan troglodytes) et des macaques (Macaca mulatta et M. fascicularis) ont été utilisés pour de tels travaux, et notre analyse de séquences a démontré que l'utilisation de chimpanzés n'apporte pas d'avantage significatif malgré leur plus grande proximité phylogénétique avec l'Homme. La suite de ce travail a donc utilisé des macaques, plus facilement accessibles en France que les chimpanzés. Dans le cadre du projet européen AntiBotABE, des banques immunes exposées àla surface de phages ont été construites à partir de macaques (M. fascicularis) immunisés puis criblées, et des scFv neutralisant simultanément les toxines botuliques (BoNT) A1 et A2 en ciblant leurs chaines lourdes, et BoNT/E3 en ciblant sa chaine légère ont été isolés. D'autre part, un anticorps neutralisant de façon croisée la toxine létale et la toxine oedémateuse de Bacillus anthracis avait été précédemment isolé. Ses épitopes ont été localisés au cours de la présente thèse par une méthode tirant partie de cette réactivité croisée. Ils correspondent à la région [229-230]-[234-236] de la sous-unité LF (Lethal Factor) et à la région [229-230]-[234-236] de la sous-unité EF (Edema Factor). Le principe de cette localisation d'épitope pourrait être ré-employé pour localiser les épitopes des scFv neutralisant les BoNT. / Recombinant antibodies represent a promising approach to improve the treatment andprophylaxis of diseases caused by bioweapons. Such antibodies may be isolated from nonhumanprimates, whose immunization is much easier to conceive and realized thanimmunization of humans. Chimpanzees (Pan troglodytes) and macaques (Macaca mulattaand M. fascicularis, particularly) have been utilized for such purposes, and our sequenceanalysis has demonstrated that using chimpanzees does not bring a significant advantagedespite their closer phylogenetic proximity with humans. The rest of this thesis has thusutilized macaques, easier to access in France than chimpanzees. In the context of theEuropean AntiBotABE project, phage-displayed immune libraries have been constructed fromimmunized macaques (M. fascicularis) then screened, and scFv simultaneously neutralizingbotulinum toxins (BoNT) A1 and A2 by targeting their heavy chains, and BoNT/E3 bytargeting its light chain were isolated. On the other side, an antibody cross-neutralizing thelethal toxin and the edema toxin of Bacillus anthracis had been formerly isolated. Its epitopeshave been mapped in the course of the present thesis by a method taking advantage of itscross-reactivity. They correspond to the [229-230]-[234-236] region of LF (Lethal Factor)subunit and to the [229-230]-[234-236] region of EF (Edema Factor) subunit. The principle ofthis epitope mapping could be re-employed to map the epitopes of BoNT-neutralizing scFv.

The prevalence of rape and its widespread impunity, whether committed during armed conflict or peacetime, has been firmly condemned by the UN and its prohibition has been consistently recognised in international law. This development, however, is a rather novel endeavour. The belated response is in part a consequence of rape being characterised by such myths as sexual violence representing an inevitable by-product of war or as being committed by sexual deviants. Its systematic nature has thus been ignored as has the gravity of the offence, often leading to a culture of impunity. This was evident, for example, through the failure to prosecute crimes of rape during the Nuremberg trials, in qualifying it as a harm against a woman’s honour in the 1949 Geneva Convention (IV), or in considering it a violation located in the “private sphere”, thereby beyond regulation by international law. However, substantial efforts have been made in international law to recognise obligations for states to prevent rape. A prohibition of the offence has developed both through treaty law and customary international law, requiring the prevention of rape whether committed by state agents or by a private actor. One measure to prevent such violence has been identified as the duty to enact domestic criminal laws on the matter. The flexibility for states in determining the substance of such criminal laws is increasingly circumscribed, leading to the question of whether a particular definition of rape or certain elements of the crime must be adopted in this process. Elaborations on the elements of the crime of rape have been a late concern of international law, the first efforts made by the ad hoc tribunals (the International Criminal Tribunal for Rwanda and the International Criminal Tribunal for the Former Yugoslavia), followed by the regional human rights systems as well as the International Criminal Court. The principal purpose of the thesis is consequently the systematisation and analysis of provisions and emerging norms obliging states to adopt a particular definition of rape in domestic penal codes. The prohibition of rape and, subsequently, the process of defining the crime has been made in three areas of international law – international human rights law, international humanitarian law and international criminal law. Emerging norms in all three regimes are consequently examined in this thesis, bringing to the fore overarching questions on the possible harmonisation of defining rape in these distinct branches of international law. The study will thus provide a contextual approach, aiming to evince whether the definition can be harmonised or if prevailing circumstances, such as armed conflict or peace, should necessarily inform its definition. Ultimately, the advances in international law are evaluated in order to identify possible areas for further development.

Magister Artium - MA / In 1987 Ntombikayise Priscilla Kubheka was abducted, tortured, killed and her body dumped by apartheid security police. She was an uMkhonto WeSizwe (MK), the armed wing of the African National Congress (ANC), commander based in Durban and was in charge of weaponry storage and organised safe houses for those returning from exile. Amnesty applications and perpetrator testimony given at the Truth and Reconciliation Commission’s (TRC) amnesty hearings alleged that Kubheka had died, while being interrogated, from a heart attack. The perpetrators claimed the heart attack was possibly as a result of Kubheka being overweight.

Many studies have focused on the concept of humanization of birth in normal pregnancy cases or at low obstetric risk, but no studies, at our knowledge, have so far specifically focused on the humanization of birth in both high-risk, and low risk pregnancies, in a highly specialized hospital setting. The present study thus aims to: 1) define the specific components of the humanized birth care model which bring satisfaction to women who seek obstetrical care in highly specialized hospitals; and 2) explore the organizational and cultural dimensions which act as barriers or facilitators for the implementation of humanized birth care practices in a highly specialized, university affiliated hospital in Quebec. A single case study design was chosen for this thesis. The data were collected through semi-structured interviews, field notes, participant observations, selfadministered questionnaire, relevant documents, and archives. The samples comprised: 11 professionals from different disciplines, 6 administrators from different hierarchical levels within the hospital, and 157 women who had given birth at the hospital during the study. The performed analysis covered both quantitative descriptive and qualitative deductive and inductive content analyses. The thesis comprises three articles. In the first article, we proposed a conceptual framework, based on Allaire and Firsirotu’s (1984) organizational culture theory. It attempts to examine childbirth patterns as an organizational cultural phenomenon. In our second article, we answered the following specific question: according to the managers and multidisciplinary professionals practicing in a highly specialized hospital as well as the women seeking perinatal care in this hospital setting, what is the definition of humanized care? Analysis of the data collected uncovered the following themes which explained the perceptions of what humanized birth was: personalized care, recognition of women’s rights, humanly care for women, family-centered care,women’s advocacy and companionship, compromise of security, comfort and humanity, and non-stereotyped pregnancies. Both high and low risk women felt more satisfied with the care they received if they were provided with informed choices, were given the right to participate in the decision-making process and were surrounded by competent care providers. These care providers who humanly cared for them were also able to provide relevant medical intervention. The professionals and administrators’ perceptions of humanized birth, on the other hand, mostly focused on personalized and family-centered care. In the third article of the thesis, we covered the dimensions of the internal and external components of an institution which can act as factors that facilitate or barriers that prevent, a specialized and university affiliated hospital in Quebec from adopting a humanized child birthing care. The findings revealed that both the external dimensions of a highly specialized hospital -including its history, society, and contingency-; and its internal dimensions -including culture, structure, and the individuals present in the hospital-, can all affect the humanization of birth care in such an institution, whether separately, simultaneously or in interaction. We thus hereby conclude that the humanization of birth care in a highly specialized hospital setting, should aim to meet all the physiological, as well as psychological aspects of birth care, including respect of the fears, beliefs, values, and needs of women and their families. Integration of competent and caring professionals and the use of obstetric technology to enhance the level of certainty and assurance in both high-risk and low risk women are both positive factors for the implementation of humanized care in a highly specialized hospital. Finally, the humanization of birth care approach in a highly specialized and university affiliated hospital setting demands a new healthcare policy. Such policy must offer a guarantee for women to have the place of birth, and the health care professional of their choice as well as those, which will enable women to make informed choices from the beginning of their pregnancy. / De nombreuses études ont mis l'accent sur le concept de l'humanisation des soins de naissance d’une grossesse normale ou à faible risque obstétrical. Mais, à notre connaissance, aucune étude à ce jour n’a spécifiquement porté sur l'humanisation des soins de la naissance dans les grossesses à haut et à faible risque dans un hôpital hautement spécialisé. La présente étude vise à: 1) définir les composantes spécifiques de l'humanisation des soins qui apportent satisfaction aux femmes qui cherchent des soins obstétricaux dans un hôpital hautement spécialisé; 2) explorer les dimensions organisationnelles et culturelles qui constituent des obstacles ou des facilitateurs pour les pratiques périnatales favorisant l'humanisation des soins dans un centre hospitalier universitaire très spécialisé, au Québec. Une étude de cas unique a été choisie pour notre thèse. Les données ont été recueillies au moyen d'entrevues semi-structurées, de notes de terrain, d’observation des participants, d’un questionnaire auto-administré, et de documents et d’archives pertinents. L’échantillon est composé de : 11 professionnels de différentes disciplines, six administrateurs de différents niveaux hiérarchiques de l'hôpital et 157femmes qui ont accouché à l'hôpital durant la période de l’étude. Une analyse à la fois descriptive quantitative et qualitative déductive et inductive a été réalisée. La thèse comprend trois articles. Dans le premier article, nous proposons un cadre conceptuel fondé sur la théorie de la culture organisationnelle développée par Allaire et Firsirotu (1984). Le but de cet article est d’examiner les tendances d’accouchement en tant que phénomène de culture organisationnelle. Le second article, répond à une question spécifique : quelle est la définition des soins humanisés selon les administrateurs et des professionnels multidisciplinaires oeuvrant dans un hôpital hautement spécialisé, ainsi que celle des femmes soignées dans cet hôpital ? L'analyse des données permet de ressortir les thèmes suivants sur la perception de l'humanisation de la naissance : les soins personnalisés, la reconnaissance du droit desfemmes, des soins humains, des soins centrés sur la famille, la défense des femmes et de leur compagnon, le compromis de sécurité, le confort et l'humanité, et les grossesses non stéréotypées. Les femmes à risque élevé et à faible risque semblent plus satisfaites des soins s'ils sont fournis selon un choix éclairé et qu’elles ont participé au processus décisionnel, tout en étant entourées par des fournisseurs de soins compétents, qui soignent de façon humaine et font des interventions médicales lorsque requises. Les perceptions des professionnels et des administrateurs à propos de la naissance humanisée mettent principalement l'accent sur des soins personnalisés et centrés sur la famille. Dans notre troisième article, nous traitons les composantes internes et externes d'une institution, qui prédisposent ou qui empêchent un hôpital spécialisé et universitaire affilié au Québec d'adopter des soins humanisés de naissance. Les résultats révèlent qu’à la fois des dimensions externes d'un hôpital hautement spécialisé, -son histoire, son affiliation, et ses contingences - ainsi que des dimensions internes- sa culture, sa structure et ses individus - peuvent tous influer sur l'humanisation de la pratique des soins de naissance dans un tel établissement, que ce soit séparément, simultanément ou en interaction. Nous avons donc conclu que l'humanisation des soins de naissance dans un l'hôpital hautement spécialisé doit répondre à tous les aspects physiologiques et psychologiques des soins périnatals dont le respect des craintes, des croyances et des valeurs et besoins des femmes et de leur famille. L'intégration de professionnels compétents et attentionnés utilisant la technologie obstétrique améliore le niveau de certitude et d'assurance dans les grossesses à haut et à faible risque dans un hôpital hautement spécialisé. Enfin, l'humanisation de l'approche de la naissance dans un centre hospitalier très spécialisé et universitaire affilié requiert des nouvelles politiques de système de santé. Une telle politique garantit, pour une femme enceinte dès le début de sa grossesse, une place dans une institution, un professionnel de la santé de son choix et la possibilité de faire des choix éclairés tout au long du processus de la naissance.

Many studies have focused on the concept of humanization of birth in normal pregnancy cases or at low obstetric risk, but no studies, at our knowledge, have so far specifically focused on the humanization of birth in both high-risk, and low risk pregnancies, in a highly specialized hospital setting. The present study thus aims to: 1) define the specific components of the humanized birth care model which bring satisfaction to women who seek obstetrical care in highly specialized hospitals; and 2) explore the organizational and cultural dimensions which act as barriers or facilitators for the implementation of humanized birth care practices in a highly specialized, university affiliated hospital in Quebec. A single case study design was chosen for this thesis. The data were collected through semi-structured interviews, field notes, participant observations, selfadministered questionnaire, relevant documents, and archives. The samples comprised: 11 professionals from different disciplines, 6 administrators from different hierarchical levels within the hospital, and 157 women who had given birth at the hospital during the study. The performed analysis covered both quantitative descriptive and qualitative deductive and inductive content analyses. The thesis comprises three articles. In the first article, we proposed a conceptual framework, based on Allaire and Firsirotu’s (1984) organizational culture theory. It attempts to examine childbirth patterns as an organizational cultural phenomenon. In our second article, we answered the following specific question: according to the managers and multidisciplinary professionals practicing in a highly specialized hospital as well as the women seeking perinatal care in this hospital setting, what is the definition of humanized care? Analysis of the data collected uncovered the following themes which explained the perceptions of what humanized birth was: personalized care, recognition of women’s rights, humanly care for women, family-centered care,women’s advocacy and companionship, compromise of security, comfort and humanity, and non-stereotyped pregnancies. Both high and low risk women felt more satisfied with the care they received if they were provided with informed choices, were given the right to participate in the decision-making process and were surrounded by competent care providers. These care providers who humanly cared for them were also able to provide relevant medical intervention. The professionals and administrators’ perceptions of humanized birth, on the other hand, mostly focused on personalized and family-centered care. In the third article of the thesis, we covered the dimensions of the internal and external components of an institution which can act as factors that facilitate or barriers that prevent, a specialized and university affiliated hospital in Quebec from adopting a humanized child birthing care. The findings revealed that both the external dimensions of a highly specialized hospital -including its history, society, and contingency-; and its internal dimensions -including culture, structure, and the individuals present in the hospital-, can all affect the humanization of birth care in such an institution, whether separately, simultaneously or in interaction. We thus hereby conclude that the humanization of birth care in a highly specialized hospital setting, should aim to meet all the physiological, as well as psychological aspects of birth care, including respect of the fears, beliefs, values, and needs of women and their families. Integration of competent and caring professionals and the use of obstetric technology to enhance the level of certainty and assurance in both high-risk and low risk women are both positive factors for the implementation of humanized care in a highly specialized hospital. Finally, the humanization of birth care approach in a highly specialized and university affiliated hospital setting demands a new healthcare policy. Such policy must offer a guarantee for women to have the place of birth, and the health care professional of their choice as well as those, which will enable women to make informed choices from the beginning of their pregnancy. / De nombreuses études ont mis l'accent sur le concept de l'humanisation des soins de naissance d’une grossesse normale ou à faible risque obstétrical. Mais, à notre connaissance, aucune étude à ce jour n’a spécifiquement porté sur l'humanisation des soins de la naissance dans les grossesses à haut et à faible risque dans un hôpital hautement spécialisé. La présente étude vise à: 1) définir les composantes spécifiques de l'humanisation des soins qui apportent satisfaction aux femmes qui cherchent des soins obstétricaux dans un hôpital hautement spécialisé; 2) explorer les dimensions organisationnelles et culturelles qui constituent des obstacles ou des facilitateurs pour les pratiques périnatales favorisant l'humanisation des soins dans un centre hospitalier universitaire très spécialisé, au Québec. Une étude de cas unique a été choisie pour notre thèse. Les données ont été recueillies au moyen d'entrevues semi-structurées, de notes de terrain, d’observation des participants, d’un questionnaire auto-administré, et de documents et d’archives pertinents. L’échantillon est composé de : 11 professionnels de différentes disciplines, six administrateurs de différents niveaux hiérarchiques de l'hôpital et 157femmes qui ont accouché à l'hôpital durant la période de l’étude. Une analyse à la fois descriptive quantitative et qualitative déductive et inductive a été réalisée. La thèse comprend trois articles. Dans le premier article, nous proposons un cadre conceptuel fondé sur la théorie de la culture organisationnelle développée par Allaire et Firsirotu (1984). Le but de cet article est d’examiner les tendances d’accouchement en tant que phénomène de culture organisationnelle. Le second article, répond à une question spécifique : quelle est la définition des soins humanisés selon les administrateurs et des professionnels multidisciplinaires oeuvrant dans un hôpital hautement spécialisé, ainsi que celle des femmes soignées dans cet hôpital ? L'analyse des données permet de ressortir les thèmes suivants sur la perception de l'humanisation de la naissance : les soins personnalisés, la reconnaissance du droit desfemmes, des soins humains, des soins centrés sur la famille, la défense des femmes et de leur compagnon, le compromis de sécurité, le confort et l'humanité, et les grossesses non stéréotypées. Les femmes à risque élevé et à faible risque semblent plus satisfaites des soins s'ils sont fournis selon un choix éclairé et qu’elles ont participé au processus décisionnel, tout en étant entourées par des fournisseurs de soins compétents, qui soignent de façon humaine et font des interventions médicales lorsque requises. Les perceptions des professionnels et des administrateurs à propos de la naissance humanisée mettent principalement l'accent sur des soins personnalisés et centrés sur la famille. Dans notre troisième article, nous traitons les composantes internes et externes d'une institution, qui prédisposent ou qui empêchent un hôpital spécialisé et universitaire affilié au Québec d'adopter des soins humanisés de naissance. Les résultats révèlent qu’à la fois des dimensions externes d'un hôpital hautement spécialisé, -son histoire, son affiliation, et ses contingences - ainsi que des dimensions internes- sa culture, sa structure et ses individus - peuvent tous influer sur l'humanisation de la pratique des soins de naissance dans un tel établissement, que ce soit séparément, simultanément ou en interaction. Nous avons donc conclu que l'humanisation des soins de naissance dans un l'hôpital hautement spécialisé doit répondre à tous les aspects physiologiques et psychologiques des soins périnatals dont le respect des craintes, des croyances et des valeurs et besoins des femmes et de leur famille. L'intégration de professionnels compétents et attentionnés utilisant la technologie obstétrique améliore le niveau de certitude et d'assurance dans les grossesses à haut et à faible risque dans un hôpital hautement spécialisé. Enfin, l'humanisation de l'approche de la naissance dans un centre hospitalier très spécialisé et universitaire affilié requiert des nouvelles politiques de système de santé. Une telle politique garantit, pour une femme enceinte dès le début de sa grossesse, une place dans une institution, un professionnel de la santé de son choix et la possibilité de faire des choix éclairés tout au long du processus de la naissance.

Cette thèse analyse l’évolution des imaginaires de la grossesse depuis 40 ans ainsi que certaines de ses incidences sociales.La science embryologiste avait installé depuis le 19ième siècle une tradition de représentation réaliste du foetus humain. Au cours de la 2ième moitié du 20ième, les choses semblent changer. En 1970, les photos de Lennart Nilsson notamment ont coloré, autonomisé, esthétisé et humanisé le foetus. En France, le ‟foetus anatomique” s’est vu par ailleurs retiré des muséums, son image s’absente du ‟Larousse médical illustré” et des manuels de sciences naturelles. Quant au foetus présent dans l’art contemporain, il est surdimensionné ou dégoûtant : ce qui ressemble donc le plus à un ‟vrai” foetus se déréalise. L’haptonomie et certaines technologies autour de la grossesse vont accentuer ces modifications de l’image du foetus au profit des imaginaires parentaux.Les effets sociaux de cette idéalisation foetale sont variés. L’humanisation du ‟beau foetus” enlaidissant l’anomalie, la hantise maternelle du ‟monstre foetal” est d’avantage intériorisée et trouble le travail en médecine foetale. Leur refus de l’anomalie devenant plus implicite, médecins et parents adoptent un langage euphémisé. Mais même l’image du foetus avorté s’humanise. Elle devient émouvante. Quand un foetus est condamné, il faudra donc le réparer, concrètement et symboliquement. Les soignants qui invitent les parents à voir le foetus après sa mort vont le présenter comme un bébé dormant, réparé de ses malformations. Certaines mères, surtout quand elles envisagent une nouvelle grossesse, le représentent alors comme un ange, cet ange devenu omniprésent sur les forums Internet.Ce dispositif questionne les sociétés contemporaines : les spécialistes de médecine foetale se retrouvent aujourd’hui confrontés à certains parents refusant la naissance d’un enfant atteint de malformations sans gravité. Au miroir de leur bébé surgit un indicible : l’horreur d’un foetus porteur d’anomalie. L’esthétisation ne rend-elle pas les imaginaires de l’anomalie d’autant plus puissants qu’ils n’ont plus d’espace, autre que le for intérieur, pour se déployer ? / This thesis analyses the evolution of imagination of the pregnancy for forty years as well as some of its social incidences.The science embryologist had installed since the 19 th century a realist tradition of presentation of the human foetus. During half of the 20 th, things seem to change. In 1970, the photographs of Lennart Nilsson in particular coloured, empowered, aestheticized and humanized the foetus. In France, the ‟anatomical foetus” saw itself besides out-of- the way of the museums, its image absent in in the ‟illustrated medical Larousse” and the textbooks of natural sciences. As for the foetus present in the contempory art, it is oversized or disgusting : what looks like mots of ‟real” foetus derealises. The haptonomy and certain technologies around the pregnancy are going to stress these modifications of the image of the foetus for the benefit of parental imagination.The social effects of the foetal idealization are varied. The humanisation of the ‟beautiful foetus” making ugly anomaly, the maternal obsession of the ‟foetal monster” is more interiorized and discorders work in foetal medicine. Their refusal of anomaly becoming more implicit, doctors and parents adopt an euphemized language. But, even the image of the aborted foetus fallen through humanizes. It becomes moving. When a foetus is condemned, it will thus have to be repaired concretely and symbolically. The nursing who invite the relatives to see the foetus after his death will present him as a sleeping baby, repaired by his deformations. Certain mother especially when they envisage a new pregnancy, represent him then as an angel, this angel become omnipresent on the Internet forums.This dispositf questions the contemporary societies : the specialists of foetal medicine are faced with certain parents refusing the birth of a child affected by deformations without gravity. In the miror of their baby appears an unspeakable : the horror of an expanding foetus of anomaly. Does not the esthetisation make the imagination of the anomaly all the more powerful as they do not have more space other than the heart of hearts to spread ?