Influência intergeracional no cuidado do coto umbilical do recém-nascido

O estudo teve como objetivo conhecer as inter-relacoes geracionais que interferem no cuidado do coto umbilical do recem-nascido. Pesquisa descritiva, de abordagem qualitativa, fundamentada na Teoria da Diversidade e Universalidade do Cuidado Cultural, realizada no municipio de Jequie-Bahia com 29 sujeitos, sendo 10 puerperas e 19 familiares cuidadores. Os dados foram coletados por meio de entrevista semiestruturada, observacao participante subsidiada pelo diario de campo. Os dados foram submetidos a analise de conteudo. Os resultados demonstraram a influencia dos valores culturais no sistema familiar intergeracional, no processo de cuidar, de modo a promover riscos de adoecimento referente as praticas populares de cuidados do coto umbilical. Assim, as acoes educativas necessitam considerar o contexto cultural dos sujeitos envolvidos, de maneira a promover a congruencia entre os saberes popular e o cientifico.


INTRODUCTION
To unveil the state of art about the present theme was not an easy task and we have discovered, through database research, concerning the infections affecting the umbilical stump on newborns (NB), that this is a field with scarce studies published in a period of twenty years (from 1990-2010).The majority of the studies were found in technical obstetric books, textbooks, with the rare exception of some scientific articles.
It is important to note that it ended in 1990, two years before the implementation of the Neonatal Tetanus Eradication Plan (NTEP) in Brazil; based on the understanding that, after twenty years, the information about the studied theme would have been contemplated in relation to the evaluation of clinical and therapeutic aspects -a conception that was also identified in a study undertaken in the period between 1986 and 1997 in the state of Bahia, 1 in which the author identified that, amongst the 1024 patients participating in the study, 156 were cases of neonatal tetanus in a hospital specialized in infectious-contagious diseases in Salvador, Bahia.
Another information that attracts our attention is related to the fact that, according to the Brazilian Health Surveillance Agency, there were 66 cases of neonatal tetanus in Brazil from 2003 to 2008, presenting a higher incidence in the North and Northeast regions, with respectively 26 (39%) and 30 (45%) cases in this period in comparison to the other states, which shows to be a public health problem.
In this context, it can be noted that there is a need for an increase in the dissemination of information about this theme and its importance in the care of newborns' umbilical stumps.
Therefore, it is evident that the neonatal tetanus still figures in the human life universe of this "little being" in the 21 st century, in particular in remote communities under the risk of low immunity due to lack of the anti-tetanus vaccination in women during the fertile years, home births with the assistance of traditional midwives, low access to prenatal examinations within difficult access areas and qualified professionals to provide adequate care to women`s health. 2 There is still the need for professional guidance related to the care provided by family members and its many forms, which are tied to intergenerational cultural knowledge.
Based on the above, it can be stated that there is the need to understand that the NB is a new human being who has just been born, who will grow up and develop in an environment different from the one (s)he has been created in, the mother's womb.Their lives will largely depend on the care of another human being, family members who they will share their lives with, particularly in relation to the answers that the new environment will provide to their most important needs, which are feeding, umbilical stump care, affection and physical safety in this stage of life. 3rom this understanding, the core of the theme was reached, which is the care of the newborns' umbilical stumps, and results from the manner in which the family takes care of it, involving the use of non-medical products as an element of a culture transmitted between generations in the practice of umbilical stumps' care and which the family care givers consider beneficial to the NB.These are the knowledge and customs acquired in the socio-family context, which these caregivers are part of and live in daily.The intergeneration is put into perspective in the study by the care knowledge-actions within the family group, which is passed between generations and involves cultural values.Culture is an intrinsic value to all human beings, and this is the reason why many academics, specially the ones in the health care area, seek to understand the meaning given by people to the process health-illness.
] The transmission of intergenerational cultural values allows the identity of a family to continue through a legacy of rituals and myths, based on some situations related to the most rigid and inflexible habits and attitudes.Therefore, it refers to a function universally organized with a structuring character, as the rituals, beliefs and values passed through generations repeat and reinforce the affective connections that will be built within the next generations. 6n this perspective, the attention to the intergeneration related to the NB's health care generally focuses on the grandmothers' role.Most of the times, they are close to their grandchildren and in charge of the domestic-family care, since their grandchildren's birth until all other stages of their Linhares EF, Silva LWS, Rodrigues VP, Araújo RT lives; their knowledge is recognized in the group they belong to, and this allows them to see the continuity of their origin.In this family context, women who are mothers and grandmothers are constantly present, participate with their experience and take on the care of the NBs. 7his is an understanding that has been acquired during our professional experience but that also affects the scientific field, it is about the health care of the human beings as viewed in multiple dimensions of the family context and with the perspective to consider the grandmother as a person who is respected and valued in the family structure organization.She is a person who contributes to the continuity of future generations and takes on the care role, therefore assisting with the health needs of not only the puerperal woman, either her daughter or daughter-in-law, but above all with the health needs of the NB.She represents a strong figure in the family's relationships associated to the new generations, 8 who is always present and also wishes that their daughters choose and decide according to the view that they, as older women, have improved during their lives. 9lso, the treatment of the umbilical stump using non-medical products beyond the domesticcommunity occurs in the maternity hospital -Rooming-In Unit.This fact points to the need for health professionals to know the various ways to deliver care and the beliefs that form part of this care, taking into account not only the highest effectiveness related to the knowledge, but also the potential forms of caring to better serve the NB.] At this point, the Cultural Care Diversity and Universality Theory is elected as the base for this study, as care is considered the essence of the nursing profession, based on the understanding of the cultural influences on the process of human beings' lives.
In that sense, culture is understood through the values, beliefs, rules and ways of life that are practiced and guide thoughts, decisions and actions and which were learnt, shared and transmitted by particular groups. 11hese discussions results in the intention for this study to contribute to the umbilical stump of the NB and generate subsidies to the education area by sharing the theoretical and practical knowledge that guide the care practice of the NB's umbilical stump, therefore providing new knowledge to students in nursing and related areas, besides encouraging further studies and research in this direction with a view to health promotion, prevention and cure of the umbilical stump's infections and further approximation between care services and the academic world.
Based on the above, the present study is aimed at exploring the intergenerational relationships that affect the care practice of newborns' umbilical stumps.

METHOD
This is a qualitative study undertaken in a city located in the countryside of the state of Bahia, Brazil, during the period between November 2009 and January 2012.The research involved the participation of 29 people, ten of whom were puerperal women and 19 were their family members.The following selection criteria were used: 1) puerperal women admitted to the Rooming-In Unit of the public maternity hospital who resided in the city where the research was undertaken and, 2) people nominated by the puerperal women as being the NB's caregivers in the domestic context.
Data collection was done through semistructured interviews and participant observation.The interviews took place at the participants' homes, were done individually and tape-recorded.Afterwards, they were fully transcribed and identified in the text by the number of the family (numerical order of interviews).Each participant was identified by a nickname related to a Brazilian plant.The statements of the participants were preserved in their colloquial format and without orthographic and/or grammatical corrections.
The observation stage, which also took place at the families' homes and followed a systematic script, did permit freedom to observe the participants and involved questions related to: the relationship between the mother/caregiver and their children during umbilical stump care, types of care provided, how the family members expressed their feelings and care, how the family organized themselves in order to care for the puerperal and the NB, existence of family member/ members with authoritative behaviors, intervention on the part of the researcher in relation to the family's process of care of the NB, the understanding showed by the mother and the family members concerning the orientation given and its practice, amongst others.This strategy was Intergenerational influence on the care of newborns' umbilical... based on the understanding that human behavior is better understood when related to the social context.Consequently, participant observations made it possible to build a comprehensive mosaic through the combination of the interviews.The information obtained during the observations was registered in the field diary and used the recent memory resource.
The research complied with the rules of Resolution 196/96. 12The project was approved by the Ethics and Research Committee (ERC) at Universidade Estadual do Sudoeste da Bahia (UESB), under registration number 188/2009 and the participants of the study signed an Informed Consent Form before the interviews took place.
] As a result, interpretation started in the analysis of the information since the beginning of the data collection, through the reading and re-reading of the emerging themes, which were grouped into thematic categories, in an interpretative mosaic in the light of a socio-anthropological scientific background.
Temporary conclusions were developed based on this process until its ending, so that the interpretations were constantly verified for validation and resulted in two categories and three sub-categories, which were submitted to a strict critique, aimed at seeking, amongst observation, those facts that could contradict the validity of the study, [13][14] taking into account the ethical aspects and the emerging social return for the scientific community and in general.

RESULTS AND DISCUSSION
After the organization and analysis of the experimental data resulting from the participants' statements, three categories and subcategories emerged, as per following.

The family support network in care and in the valorization/recognition of the care the puerperal woman provided to the NB
The puerperal women's umbilical stump care is an act that is based on the family history, is reflected in the manner of her care and involves the cultural knowledge acquired from other gen-erations, with greater influence from the closest family members.
This process of close relationship directs the ways in which the care is expressed in the family, taking a complex direction formed by knowledge, beliefs, arts, moral, laws, customs and all and/ or any ability or habits acquired by the human being as the member of a society. 15Also in the puerperal women's views, the care was molded by the meaning given to the umbilical stump, by the experience and express forms acquired from the intergenerational environment they are part of.
It can be noted that the family support relationship is an important dimension of its functionality, taking into consideration that this relation is usually accompanied by an important affective connection involving the puerperal, the NB, and all the family, in a socio-cultural environment in which the puerperal is a part of, and it also extends to other people with some degree of proximity in the community. 16ithin this category, the family presence can be observed, contributing not only to the umbilical stump care and the NB's bath, but also to the housework in general, as well as the concern with the health condition of the puerperal, who is in a stage of vulnerability.Despite the fact that these tasks are generally performed by the members of the family, the help of other people from the social network can be also noted.
The puerperal woman's support network is considered as protection, understanding, affection, responsibility and cohesion, essential aspects in the friendly relationship of the family, which represents the social connection network of the puerperal woman, a fact that was shown in the participants' statements in relation to the subcategories, called the factual description of the support and its effect in the current care practices adopted based on her personal history.

The family union to provide care to the NB
The analysis of this subcategory reveals that the puerperal women who participated in this study could count on the support of their family members, in particular the NB´s maternal and paternal grandmothers, and this shows a link of belonging based on love and mutual support, in which the family is the source of primary care in the relationship among its members.In addition, the puerperal women could also count on the support of other people close to them, sisters-in-Linhares EF, Silva LWS, Rodrigues VP, Araújo RT law and neighbors, for the housework and care of the NB.This type of support was also offered to the puerperal women, taking into consideration their psychological and physical change due to the birth process.
The family and the other members of the close connection network performed the duty of caregivers, with the aim of preventing illnesses, supporting the emotional balance, sustaining relationships, solidarity and reciprocity in relation to the cultural values, as per the following statements.
My mother and my mother-in-law help me.Looking after my other boy, taking care of and bathing my new baby now.The one who bathes is my mother-in-law; she bathes and changes the clothes […] my mother takes care of the house and of my other boy.My mother-inlaw also cares for the belly-bottom during the bath, and I also do (Family 5, puerperal woman-second child, Lilly).
My sister-in-law, my brother's wife, helps me to bathe the baby, to put on 70% in the baby's belly-bottom, to change him, to look after him, to take care of him.Only from inside the house that […] help to take care of the baby.On Saturdays, Sundays, when my mother is at my house, she also helps me to look after him; everyone helps in this house […], but the one who mostly looks after him is my sister-in-law (Family 6, puerperal woman-first child, Cactus).
[…] the neighbor always helps to change the nappy, to hold, she always helps to get the baby when he is in bed crying […] (Family 3, puerperal-womanthird child, Orchid).
From the statements, the participation of the family and friends in help with housework and care for the NB was identified, reinforcing the studies about women being caregivers by nature.This gender issue is also evident in this study.Although the father's presence was identified in the NB's care, this care was mostly related to holding and bathing, providing financial resourcesfeeding and other expenses -while the puerperal woman and/or other female members, in addition to caring for the NB, performed the housework.
This care relational approach finds support in other studies [4][5][6][7][16][17] when it states that the existence of another human being, the NB, introduces collective efforts to the new generations, which assists the strengthening of family connections related to belonging and social contact. Accoring to the socio-anthropological approach, this results in the activation of the family as a subject or, in other words, in the intensification of the subjective relations among family members, and also in the valorization of other characters who are also part of the social network support.

Family members valuing the puerperal woman´s care of the NB
From a young age, women acquire knowledge that older and more experienced people in their home context disseminate, so that these women can also develop the acquired knowledge once they reach adult age.They build, in their daily lives, their care related actions based on their socio-cultural life history, they seek and use this knowledge acquired in the social environment they belong to within the intergenerational context.In some of the statements, however, it can be noted that the care related actions were based on those of the health care professionals and, in these cases, little proximity with the family was noted for different connotations, with some families presenting resistance and not accepting the professionals' orientations relating to the care for the NB's umbilical stump.
These are attitudes and behaviors resulting from the existence of knowledge-actions; for the care of the umbilical stump, for example, on one side, the professional recommends the use of 70%alcohol, as recommended by the Brazilian Ministry of Health 17 and, on the other hand, the families who bring their experience resulting from a family history of care, as the use of tobacco, chicken feather, shoe sole, manure and other ingredients which are related to their culturally transmitted orientations of care practices.This does not mean, however, that communication between the knowledge-actions has been closed but, on the contrary, relational mediations before and beyond communication are being established and, as a consequence, the convergence of knowledge from the perspective of the NB's health.
In the statements below, the valorization by the family members of the care developed by the puerperal women in the performance of their mothers' duties in order to ensure the NB's survival can be evidenced.This valorization granted by the family members to the puerperal women has been positive in relation to the emotional balance, safety and self-confidence and has permitted the execution of knowledge-actions as noted below: […] we put the bath on top of the sink, the sink used to wash dishes all sterilized already, she [puerperal woman] throws alcohol in the bath, and put the Intergenerational influence on the care of newborns' umbilical...

bath with that thing open [bath lid] and I start pouring the water; she does not even let me touch the baby. She washes with a mug, very well washed, washes everything well, leaves it all right, you should see how careful she is (Family 7, maternal grandmother Sunflower).
[…] I think this care is right, because I think the belly bottom gets better quicker, because now that they are no longer using these things.Because now it stays the same way it was when they returned from the hospital, the children cry a lot because they can feel pain as a result, with the belly bottom sometimes dry.And, sometimes, we already have got our mother's traditions.And then we will try to use them with the children.I taught my daughter how to care for the baby's belly bottom and she is doing it all correctly, the same thing (Family 10, maternal grandmother, Violet).
It is evident from the statements that the valorization on the part of the family promotes the puerperal woman's independence to care for the NB's umbilical stump, encourages trust and instigates the puerperal woman to the knowledgeaction, taking decisions and allowing her personal growth, which is expressed through responsibility and concern in relation to the child's dependency on her.In the same way, this information was identified in a study involving teenager mothers, in relation to the meanings given to the care of their babies 18 and showing that there is, in our way to view it, a human identity for maternity, or in other words, a natural ontological and phylogenetic passage -family and culture.
The family as an encouraging factor is therefore a network of perspective and development of the puerperal woman's care potentials concerning her choices, because it is within the family that generations share their daily experiences.As a result, the closer relationship between the knowledge of the family and the professionals is a necessary condition, in so far as all the relations become significant and benefit the re-invention of the puerperal woman's knowledge-actions in her human process of taking care of her descendants more autonomously, trusting herself and valuing her care -factors that were observed in this study during the field work.
Other cases have also been noted, in which families did not recognize the puerperal woman's care ability, and also cases when the puerperal woman did not show interest in caring, leaving this task to other members of the family and to other people belonging to her close social network.Therefore, there are multiple co-existing trends in the care relations; however, the family continues to predominantly assume their duties to ensure an intergenerational sociability.

The family and the social network as "learning school" to take care of the NB
The puerperal woman's social network involves the family and the people who are part of her daily life.network supports her universe of personal and cultural relationships, her identity and the environment she lives in.In this home universe, there are several and varied popular forms of knowledge, derived from a cultural standard that each family has and that were transmitted between generations.
The cultural standards sometimes overcome the professional knowledge in a way that they are based on the popular knowledge.From this view, the home context network of the puerperal woman becomes a facilitator of popular knowledge in relation to the NB's care, as shown in the statements below.
I did not do the pre-natal; the belly-bottom's care was taught to me by my mother.The hospital gave about two little tubes of 70% alcohol, but it just took long to fall off, then my mother started to do it her way, which was the way her mother had taught her.She started to use almond oil, it fell off quickly and dried (Family 10, puerperal-second child, Andorinha).
[…] I executed a lot of birth procedures […].I only gave back the children after seven days, after the belly-bottom had fallen off.I used castor oil and a bandage.I stopped (Family 9, midwife, Canaria).
I got the experience from my family, from my mother, from my grandmother […].They taught me how to take care of the umbilical stump, to watch it, to clean it, to put a little bandage to press against the belly-bottom.It comes from the family, does not it?[…] my mother, when she took care of the belly-bottom, she used to put on drying powder […].And sometimes also with chicken feather which was burnt and put on to heal fast.The tobacco powder too […] (Family 5, paternal grandmother, Avenca).
In Andorinha's statement, the popular knowledge influences her daughter's care for the umbilical stump with the use of almond oil.In this situation, during a home visit (participant observation), an infection in the umbilical stump was diagnosed; however, the puerperal woman and her genitor did not have the perception of what was happening with the NB, and at that moment, the need for knowledge proximity through the use of the health education strategy was evident Linhares EF, Silva LWS, Rodrigues VP, Araújo RT to make both the puerperal woman and her genitor understand the extension of the risk to the NB, thus making it possible for them to re-evaluate the care practices for the umbilical stump and adopt the 70% alcohol.Through Canaria's statement, it was noted that she was a traditional midwife without the basic qualification to apply prophylactic measures, which would give her conditions to apply a healthier care concerning the prevention of diseases.The traditional midwife is considered an experienced woman who provides advice and is respected by the people in her social network and this makes her a reference of reliability within the family care relationships.She assists with natural home births, using her care practices based on rituals, prayers, symbols, popular superstitions and beliefs -the knowledge that she has was acquired from other midwives, being this knowledge also retransmitted to the new generations and resulting in another midwife in the same family.Generally, she provides care without financial return and does it for solidarity and satisfaction for the life of the human being that is about to be born, as well as for the life of the woman giving birth, in a bloom of the natural genesis of life.
In these statements, the importance of the knowledge built on the family generational context and on the social support network is a fact and it is validated by the culture that supports the ways to care.It is shown through the participants' statements that this undoubtedly needs to be put into perspective for the professional care actions, in a respectful negotiation, where knowledge joins actions in order to promote the health of the NB.
In this context, the balance between knowledge and actions constitutes a technological strategy of the care from the nursing care point of view.2][13][14][15][16][17][18][19] So, in other words, the balance seems to be the proximity of meanings which involve the family in its cultural relation network of coexistence and membership.

The popular knowledge as essence of the home-family care, multiple ways of caring
As seen in the previous category, the family is involved in the process of caring for its members according to the health and disease concept acquired in the socio-cultural environment where they live and relate to others.In the same way, this category meets these care perceptions, which assists with the health care needs of the family in the home environment.
The care, therefore, consists of various ways of living, thinking and expressing in the world.It consists in the commitment of the human being to promote the wellbeing of others, considering the adversities that life presents to them. 19This human care is the essence of ethical and moral values, which permeates the family members in their intergenerational roles.
Within this category, the subcategory -Cultural intergenerational values in the care for the NB -broadens the understanding about the multi-factor experiences of family care.To understand these values under their authors' perspective, it is essential to approach the care of the NB, as human beings develops and applies the care according to their culture and their conception of health and sickness.
Leininger 11 states that the care is universal and it is the forms of care that diverge according to the influence of the cultural factors transmitted between generations.The culture, however, involves values, beliefs and ways of living which were learnt, shared and transmitted and which direct thoughts and decisions in the care practice. 11he following statements bring up the importance of the culture in the design of the multiple forms of care for the participants of this study.

Oh, I looked after my children's belly-bottom […] now, those times, I treated with castor oil. And, when the belly-bottom fells after three days, I used tobacco powder […]. Now, on this one I used tobacco powder and castor oil […]
The tobacco is good for the child not to get those diseases, the seven days' disease […] the baby starts to shake, and some of them die, and the tobacco powder (Family 9, midwife, Canaria).
Yesterday, my baby completed seven days, my friend told me not to take the baby outside, and not to bathe, not to throw anything away, […] and to put a little pair of scissors under the pillow […], because of the seven days' disease.Sometimes children contract a pain called colic, get bad vibrations […] that pain starts, the squeezing, contract through this; the child cannot handle it and dies.I put the pair of scissors under the pillow to send the seven days' disease away, specially the bad one.It is a disease that is brought by the wind and attacks the child, the child becomes all deformed.With the pair of scissors under the pillow, this does not happen.There, the seven days' disease goes away (Family 9, puerperal woman-second child, Jasmine).
From these participants' statements, the influence of cultural values can be observed, reflected in Intergenerational influence on the care of newborns' umbilical... the care practices that relate to the umbilical stump and in the fear of the risk of the NB's death, which is known as the 'seven days' disease'.In the scientific field, it is known as neonatal tetanus.
It can be pointed out that some 'beliefs' do not cause damage to the NB´s health, but there are those which put them at risk of contracting an infection in the umbilical stump and this can cause sepsis.The use of substances that can cause infections was mentioned in the statements.These infections, if not treated, can become serious. 20In relation to this, the participants' concern with the 'seven days disease' can be observed.
So, the family is based on values, beliefs, knowledge and practices, and its system is built based upon the care explanatory model. 21This model promotes the functionality in the dynamics of their existence in order to promote their members' health.This is the knowledge that causes concern to other academics 22 , in relation to health education and people's quality of life.
Concerning this care aspect, for the re-standardization of cultural care to occur, actions and decisions taken by professionals who are supporting, assisting, facilitating or capacitating should be included, with the purpose of helping the puerperal woman, the family and the neighborhood network to (re)-evaluate-organize-reflect about their care practices, so that changing or modifying them can be a consensual decision among the stakeholders involved in care. 11n this context, the health care standard, which is new, different, beneficial and differs from the previous one, which was traditional, linear and absolute, and disregarded people's knowledge, must be based on the respect for the cultural values and for the people's beliefs, providing a beneficial and healthier way of life than the previous one and making changes be co-established by professionals/individual/family/community, so that they are accepted.
From the cases shown, practices can be observed that do not bring any risks or cause damage, but there are others that need proximity and trust strategies between the participants and the health professionals, aiming at bringing these practices closer and directing them to the health-disease process of the human being.

FINAL CONSIDERATIONS
This study showed the importance of considering families in their subjectivity and in their different care practices concerning the NB's umbilical stump as the first human social network and as recognized by socio-anthropological literature.
The care developed by the families involved in this study is based on cultural values that are transmitted between generations, in addition to other practices, and result from the social network they belong to.
According to the results, it is understood that this care is involved in complexity and there is a need for an integrative view of the popular scientific practices in relation to the care of the umbilical stump, which is so surrounded by myths.Therefore, congruence can be reached in a respectful manner, mainly when taking into consideration the representations of the families about the aspects related to their members' health.
In regards to this aspect, the reflection related to the nursing qualification emerges in the continuous development of inter-disciplinary potentialities, with human and social sciences seeking for knowledge and having in mind its actions relating to people -human beings surrounded by cultural values.As seen through the participants' statements, their ways of looking after the NB's umbilical stump are based on family history.Thus, the family appears as a relational mediation system in order to bring the professional knowledge closer to the NB.
In this sense, attention should be drawn to the fact that, besides working with the pregnant woman during the gestational period, extending the actions to the puerperal period, it is necessary to consider the social network she belongs to as being a socio-political strategy for the NB's health or, in other words, to extend the protection and prevention actions to the educational field that includes the cultural knowledge, being those of a human relational proximal nature, especially in the reality of a multicultural diversity country, considered as being the several 'Brazis'.