Collective memory of umbilical cord stump care: an educational experience

Rev Bras Enferm. 2019;72(Suppl 3):360-4. http://dx.doi.org/10.1590/0034-7167-2018-0735 ABSTRACT Objective: To report the educational experience with pregnant women considering the recovery of collective memory inherited from the care for the umbilical cord stump provided by grandmothers. Method: This case study was based on collective memory and resulted from a workshop with 20 pregnant women from a Basic Health Unit in a city in the inland of Bahia. Results: The study showed that pregnant women’s grandmothers are significant in the stump care process because they transmit their memories pervaded by beliefs, myths and superstitions that, although should be respected by nurses and other health professionals, can sometimes contribute to the occurrence of omphalitis and neonatal tetanus. Final considerations: The results indicated the need for raising awareness and education of all persons involved in this care, especially grandmothers, so that they can reflect on the risks and damage that certain empirical knowledge can cause to the health of the umbilical cord. Descriptors: Care, Memory; Health Education; Umbilical Cord; Culture; Tetanus.


INTRODUCTION
After the umbilical cord is cut, it is called umbilical cord stump and must undergo a physiological process of dehydration and mummification in order fall in a period between 10 to 15 days, remaining only a scar, popularly known as belly button (1) .
During this process, the stump must be kept clean and dry and its bandage must be made after diaper change and shower.The technique for performing this procedure has undergone several changes over the years.In 2001, the standard guideline for the use of 70% ethyl alcohol was established, in which the stump and the surrounding area should be uncovered in order to an adequate aeration that favors the rapid mummification and fall occurs in less time (1)(2) .
The safety in this care also requires the action to be preceded of hand washing with soap and running water.Proper cleaning must be held by soaking a cotton swab or a gauze sterilized with alcohol passed sequentially from the base to the tip and, when placing the diaper, it must be folded and positioned below the stump (2) .
An important factor related to the care of this small structure relates to popular beliefs, as the use of the belly button protector band in the abdomen of the newborn (NB) as a measure to prevent umbilical hernia.One has to consider that this belief needs to be demystified, because it is scientifically proven that this procedure in no way prevents this problem, but only favors the stuffiness of the umbilical region -which should be avoided given that humidity and heat are factors that favor the proliferation of bacteria which may cause umbilical infection, neonatal tetanus and evolve to death (1)(2) .
It is known that sometimes empirical knowledge about care to the umbilical cord stump may contribute for the occurrence of serious complications that will compromise the NB' health.Therefore, promotion of preventive measures is of crucial importance for maintaining the newborn's health and well-being.In this sense, educating mothers and other caregivers about the umbilical stump care and the proper way of bathing may contribute to reducing neonatal morbidity and mortality (3) .
In this perspective, the development of extension activities in the project "Programa Educativo: a saúde do coto umbilical (Educational Program: the health of the umbilical cord stump)", developed at a university in Bahia's inland, has been offering opportunities to hold educational actions with pregnant and puerperal women as well as with other caregivers in order to reduce neonatal tetanus, omphalitis and its complications.During the execution of these actions, researchers could note that many of these caregivers, especially mothers and grandmothers, presented lack of information on the knowledge about proper umbilical cord stump care because they routinely used certain care practices that are pervaded by beliefs and myths that can compromise the NB's health.
It should be noted that during the brief postpartum hospitalization puerperal women receive guidance and demonstration about the care that should be directed to the NB.However, after returning to their residence after hospital discharge, most of them do not use the guidelines received due to their little or no experience and because they also need to rest after childbirth, delegating these activities for mothers or mothers-in-law and thus becoming vulnerable to the cultural influence of the older people in the family, who end up being responsible for the care to be given to NB, in particular the bath and the umbilical cord stump care.
At this moment, the grandmothers demonstrate their skills of cultural care pervaded by knowledge, resulting from myths and superstitions, stored in their memory and that, when remembered, use the most diverse types of materials and substances -such as chicken feather and coffee powder; almond, castor, and soy oil; talcum powder, mercury, bandage, gauzes, and coins -when taking care of umbilical cord stump, being that such substances and materials can, as previously stated, compromise the NB's health and even lead to death.
One must consider that grandmothers are crucial and stand out in the transmission of remembered cultural knowledge that are present when taking care of the umbilical cord stump of their newborn grandchild through an inherited memory.In this context, this memory is marked by the collectivity of a group or family groups, given that it is constituted in "a continuous current of thought of a continuity that nothing has of artificial, because it retains nothing from past except what is still alive or is able to live in the consciousness of the group who keeps it" (4) .
It is emphasized that to remember the events experienced, the person needs help of others because even if only one person was involved in an event in which only he/she saw or participated in, the memories are collective.In this way, the individual memory cannot be distanced from the collective memory since the individual by him or herself has no control over his or her past (4) .It should be pointed that the older person has a place of honor and privilege, which "reveals the beauty of the one who has the power to initiate a work that surely will be continued by his or her descendants" (5) .
Thus, the memories of the umbilical cord stump care are remembered at the core of one's family, being the grandmothers the keepers of the tradition of a care memory; hence the importance of actions for health education being permanently undertaken both in rooming-in practice as at home and, especially, in prenatal services, considering that umbilical infections bring serious pathological consequences, such as necrotizing fasciitis, myonecrosis and hepatic abscesses, among others.
In this perspective, myths are comprehensive factors that grandmothers transmit to their daughters, daughters-in-law and other members of their community by means of orality and their care practices.Therefore, such myths are pervaded by religious, historical, cultural, imaginary, and customs inventories guided by communication, thus allowing an inherited collective memory.
In this sense, the maintenance of this memory and its crystallization in the collective imagination by orality will find a powerful vehicle that will ensure a close relationship between the care and the knowledge of a given community (5) .In this way, the transmission of experiences between generations are linked to the memory inherited from belonging groups (4) .
Despite the technological advances on health allowing the discovery of diagnoses and treatments of pathologies with more precision and speed, this is still insufficient to abolish, in different population groups, the presence of popular beliefs and knowledge linked to the memory that is transmitted between generations in terms of maintenance of health (6) .

OBJECTIVE
To report a successful experience of education on health with pregnant women, considering the recovery of the collective memory about umbilical stump care inherited from grandmothers.

METHOD
This is a case report that considered the collective memory from a perspective of an action for education on health named "práticas e saberes do cuidado com o coto umbilical e prevenção do tétano neonatal (practices and knowledge of umbilical cord stump care and neonatal tetanus prevention)", performed by the extension project titled "Educational Program: the health of the umbilical cord stump", of the Universidade Estadual do Sudoeste da Bahia, in a Basic Health Unit (UBS) located in a city in Bahia's inland, Brazil.Twenty pregnant women registered in the prenatal service of that UBS participated in this action, among which: primigravida and secundigravida women, a nursing professor and twenty nursing students, members of this project.This action consisted of a workshop about the care for the umbilical cord stump.
Before starting the activities, pregnant women were informed about the crucial importance of their participation for learning success.Participatory method was used because it favors the relationship between educator and student and allows the involvement of each participant in the learning process and the achievement of success.This methodological instrument allows participants to exchange information for clarification of doubts and greater safety in the questions about the themes proposed (7) .That is, the instrument promotes the exchange of knowledge and experiences relating to the umbilical cord stump care and higher fixation of learning by means of dialogue.
During the development of educational activities, the themes approached were omphalitis, neonatal tetanus, NB's bath and immunization, and umbilical cord stump care in order to clarify doubts about the myths and superstitions surrounding this practice held by the usual caregivers.In addition, some resources such as posters, information booklets, samples of 70% alcohol, child mannequin for real-size simulation of the care practice for umbilical cord stump, educational folder, magazine, gauze and bathtub were used as a complement to these teaching activities.
At the end of the educational action, an evaluation moment was promoted so that puerperal women could express their feelings about the learning acquired, which was quite encouraging and motivating, since these women verbalized their interest in personally providing care to the umbilical cord stump of their children, besides regretting about the non-participation of grandmothers by understanding that this experience could be a way to raise awareness, with a consequent change of thinking in their memory.

RESULTS
The educational activities began with a dynamics in which pregnant women demonstrated how they intended to provide care for the NB, proving that wet bath and immersion bath would be the procedures used in their homes.That said, the facilitators emphasized baths in running water and immersion baths with clean water to rinse the NB, besides the cleaning of the umbilical cord stump with 70% ethyl alcohol, proper drying without use of belly button protector band, and correct placement of diapers.
Thus, when questioned about who would take care of the children's umbilical cord stump in the first days of life, the pregnant women answered that the maternal grandmothers would, showing clearly in their reports the empirical knowledge used by these grandmothers in the provision of such care and the strengthening of these knowledge -which justifies the continuity of the collective memory inherited.
In this way, the participants made explicit in their speeches that grandmothers are the primary caregivers of the umbilical cord stump within the family and that they use their popular knowledge acquired from previous generations, as not watering the stump, applying chicken feather powder and almond oil on the base, and using the belly button protector band after its fall.In addition, they described the practice of keeping the NB for 24 hours in the mother's room on the seventh day of life without bathing and without receiving visits of persons residing in other environments, justifying that these procedures were supposed to prevent illness followed by neonatal death.
After that, the presentation of themes took place in a dynamic and playful way by establishing a dialogue with the participants, so that they had a better understanding of the themes approached and mentioned their memories of umbilical cord stump care.
Most pregnant women reflected about the care to the NB when demonstrating interest in the clearance of questions, in particular when cleaning the stump, confirming that this is a target structure of myths, fears and superstitions.Their lines also evidenced that they had no knowledge on proper care, since they did not know how to manipulate the stump, or develop their practice of care; also, they were unaware about the 70% ethyl alcohol being the antiseptic recommended scientifically.

DISCUSSION
Although health professionals constantly recommend and stimulate that the practice of NB's bath should be performed daily and whenever necessary because it provides skin and umbilical stump cleansing, comfort, well-being and benefits the functioning of the circulatory system (8) , the pregnant women's lines indicated that most women have some difficulty and fear to accomplish both the hygiene of the stump, as the bath, and thus is influenced by family members, especially grandmothers and, to a lesser fraction, close neighbors.
The results showed that when maintaining the RN in the room for 24 hours on the seventh day of life, both grandmothers and pregnant women seemed not to know the effectiveness of the neonatal tetanus vaccine, because the participants presented as justification that this measure prevents the neonatal tetanus.Therefore, the gap in their knowledge when it comes to stump care and NB's bath was visible, reinforcing the need for the development of educational activities focused on omphalitis and neonatal tetanus.
As a crucial measure for prevention of this disease, there is the vaccine tetanus toxoid that every woman in fertile age, pregnant or not, between 10 to 49 years, should make use, besides the correct hygiene of the umbilical stump, since the Clostridium tetani
is present not only in contaminated and rusty metal objects, but in diverse environments, including in the hands of the one who manipulated the stump (9) , reinforcing the need for professionals to have greater involvement and commitment to the educational activities, with the purpose of strengthening the care guidelines to this structure.Thus, mothers must be clarified that when perceiving any sign of infection at the base of the umbilical stump (foul odor, hyperemia, exudate, bleeding), they must immediately seek the health professional to apply the appropriate treatment (2) , which points to the fact that health education is a practice that must be used as a teaching-learning reinforcement able to produce, in the pregnant woman and other caregivers, greater understanding about the care guidelines, with emphasis on the importance of immunization against neonatal tetanus.
The educative actions in health are considered crucial because they provide a rapprochement between health professionals, especially nurses, and the community that takes cake of the umbilical stump (pregnant women, puerperal women, and family members).Its potential ability awakens in the individual the desire of change in behavior and habits of care when leading him or her to the reflection of their practices and the perception of the need to obtain better quality of life, given that continuous education promotes health and well-being, and should therefore be carried out during the care service at the prenatal service, being extended to the inrooming and home practices for the "detection of practices that predispose to the disease, as well as for updating the vaccination calendar, both the mother's and the child" (9) .
Although pregnant women receive some guidance from professionals, it is known that generally they do not assimilate it in its entirety because they are experiencing a stage that enabled the vulnerability in their psychic state and thus end up absorbing the information provided by their family members and other people in their belonging group (8) , demonstrating the credibility that superstitions have in stump care.Pregnant women of this study prioritized the NB's grandmothers as the caregivers elected for such care.
Considering the existence of confrontation between popular knowledge and scientific knowledge, there can occur damage caused by a conduct that compromises the humans' well-being when subjected to first knowledge.Therefore, one has to consider that the popular knowledge grandmothers pass on to their daughters and daughters-in-law, somehow does not aim at the risks and damage that they may cause to the NB's health and well-being.In this sense, educational activities must be valued and worked so that pregnant women can be aware and reflect about their child's health, the importance of proper care to the umbilical stump, and the consequences in case the care is not provided properly (8) .
In this context, the individual is a being that perceives and acts according to his or her culture, is changed with the results of his or her experience and with the environment, carrying a popular knowledge transmitted from generation to generation among the family members, whose conduct can be modified according to the needs of the present; however, older persons generally resist to change in their culture (5) and, as depositories of an experience, they transfer to young persons that carefully listen to them their knowledge and wisdom, thus confirming the construction of the collective memory inherited to keep alive the existence of their memories (myths, taboos, among others) of a present past.
In this perspective, grandmothers are important figures in the domiciliary care and stand out as "sources of support in moments of difficulties within the family context, " exerting influence on their descendants, providing care with their cultural practices (10) , especially of their daughters and daughters-in-law in puerperal stage and of their newborn grandchildren and, when remembering the umbilical stump care on a daily basis, they transmit their memories pervaded by valued and respected knowledge in the home space.Consequently, it is with the help of other people from their belonging group that grandmothers evoke their past, given that no memory exists without this interaction (4) .
This study thus reaffirms that the myths, beliefs and superstitions are cultural factors that grandmothers share with family generations, which absorb the guidelines following a ritual for care.Health professionals must intervene at this moment to trigger the educational actions aiming at promoting improvement in the quality of life of the NB and his/her family, paying attention to the limits and dangers that certain empirical knowledge can generate for health.It is understandable, therefore, that grandmothers disseminate the knowledge that influences their daughters and daughters-in-law on the umbilical stump care practice, enabling, exceedingly, the support of an inherited collective memory.

Study limitations
This study had as limitation the non-participation of the caregiver-grandmothers in the workshop held, because, otherwise, they would surely have had the opportunity to reflect on the issues addressed and perhaps start presenting changes in the behavior towards the umbilical cord stump care -because it is known that memory is selective and grasps only what interests it, which was also perceived by the pregnant women at the evaluation time in the workshop.

Contributions to the field of nursing, health, or policy
Based on this successful experience, nursing has the possibility of developing educational activities aimed at the improvement of the service to newborns, with implementation of specific policy to this clientele, especially with regard to the umbilical stump, in terms of reducing neonatal tetanus and omphalitis.

FINAL CONSIDERATIONS
Educational activities about the umbilical cord stump care must be developed by the health professional, especially by the nurse that acts in the prenatal service, using strategies that enable the prevention of aggravations and contribute for the reduction of neonatal tetanus, omphalitis, and their complications.Thus, it is understood that educational activities carried out by members of the project "Programa Educativo: a saúde do coto umbilical (Educational Program: the health of the umbilical cord stump)" with the participants of this study enabled the dialogue between scientific knowledge and popular knowledge, which Collective memory of umbilical cord stump care: an educational experience Linhares EF, Dias JAA, Santos MCQ, Boery RNSO, Santos NA, Marta FEF.
are fundamental to the construction of new knowledge aimed at the child's health.
Regarding the care to the NB, health professionals knowing the myths, beliefs and taboo pervade the umbilical stump care is of fundamental importance in order to develop educative actions in health with pregnant and puerperal women, and with family members, without, however, undoing and/or disposing of the popular culture arising from an inherited collective memory.
Therefore, health professionals, especially nurses, must focus their attention not only to pregnant and puerperal women, but also to the grandmothers that take care of the NB's umbilical cord stump, because they are the memory of their belonging group, the bond that exists between its members, between past and present, responsible for the maintenance of an identity built up over generations.Their knowledge of popular care are respected and radiate in their social environment, making their memories of care put into practice more and more vivid.
The importance of grandmothers, alleged caregivers of the umbilical cord stump, being included in the health education sessions with pregnant and puerperal women is identified because when receiving guidelines on care on the part of nurses, they certainly will disseminate the information grasped during the dialogue.Therefore, the actual need to educate and make aware all persons involved in the care of the umbilical cord stump is perceived, in the sense that they can understand and reflect on the risks and damage that certain empirical knowledge can cause to the NB's health, particularly the health of the umbilical cord stump.