PRB

(August 2010) Bolivia is one of the poorest countries in South America, with a per capita income of US$4,140 that is far below the regional average of $10,150. The country has among the highest fertility and infant mortality rates and lowest average life expectancies in Latin America, and less than 10 percent of Bolivians living in rural areas have access to improved sanitation.¹

The most recent demographic and health survey (DHS), conducted in 2008, shows some improvement in infant and child health. But use of effective family planning remains low and the total fertility rate (TFR)—3.5 lifetime births per woman—declined little from the previous DHS in 2003.²

Population and Key Indicators: Bolivia

Source: Carl Haub, 2010 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2010).

Some Health Indicators Improve

In 2008, an estimated 50 of every 1,000 infants in Bolivia died before reaching their first birthday, just slightly lower than in 2003. But there are some signs that infant and child health may improve. The percentage of children ages 18 to 29 months who had received childhood vaccinations increased from 64 percent to 79 percent between 2003 and 2008.³ Coverage is lower in poorer areas and for children from lower-income families, but the disparities are not large. While one-fifth of children still have not received all recommended vaccinations, coverage is 98 percent for immunization against a form of tuberculosis, and 86 percent for the measles vaccine.

Over the same period, however, the incidence of diarrhea (in the two weeks preceding the survey) among children under age 5 edged up from 22 percent to 26 percent. Diarrhea is a major killer of young children in developing countries. Even though rates increased, nearly one-half of the children with diarrhea were treated at a health facility in 2008, an improvement over 2003, when just over one-third of children were treated.

There was a welcome rise in the percentage of expectant mothers who received prenatal care, from 65 percent in 1998 and 79 percent in 2003 to 90 percent in 2008. There was also an increase in the percentage of mothers who received skilled medical care during childbirth.⁴ In 2008, about 71 percent of births were attended by skilled medical personnel, a substantial increase from 61 percent just five years earlier. The assistance of a skilled birth attendant during childbirth is considered crucial to lowering maternal mortality, one of the Millennium Development Goals for 2015.⁵ Closing the disparity among income groups will be key to meeting this goal: While nearly all of the wealthiest mothers had skilled birth attendants in 2008, just 38 percent of women in the poorest fifth of households had a qualified childbirth attendant.

High Unmet Need for Family Planning

Helping women avoid unwanted pregnancies is another way to improve maternal health, especially if the pregnancy occurs within two years of a previous pregnancy, when a woman is under 18 or older than 34, or if a woman already had at least three births. The 2008 DHS indicates that Bolivian women are becoming pregnant before they intended to because they are not using an effective method of family planning. One-fifth of couples had an unmet need for family planning—they wanted to avoid another pregnancy altogether or to delay it for at least two years but were not using a contraceptive method.⁶

Indeed, Bolivians’ contraceptive use is quite low for South America, and it has risen only modestly over the past decade. Even more striking is the heavy reliance on traditional family planning methods. Some 26 percent of couples used a traditional method, primarily periodic abstinence, which has a high failure rate as commonly practiced. Just 35 percent of married Bolivian women were using a modern contraceptive in 2008—the same percentage as in 2003. Contraceptive use was higher among wealthier women and women with higher educational attainment, but modern use did not exceed 47 percent even among women in the wealthiest fifth of households.

With little increase in modern contraceptive use, it is not surprising that fertility declined only modestly between 2003 and 2008, from 3.8 children per woman to 3.5. This is not far below the 4.2 children per woman recorded in the 1998 DHS.

The 2008 DHS also indicates that the “wanted” fertility rate is 2.0 children, about 1.5 children below the current TFR. Fertility is unlikely to fall further without an increase in the use of effective contraceptives that allow women to avoid pregnancies they do not want. Increasing contraceptive use will require expanding access to supplies and methods, as well as informing more women about their options for preventing an unintended pregnancy.

Mary Mederios Kent is a senior demographic writer at the Population Reference Bureau.

References

1. Carl Haub, 2010 World Population Data Sheet (Washington, DC: Population Reference Bureau, 2010), accessed on Aug. 3, 2010.
2. Ministerio de Salud y Deportes (MSD) et al., Enquesta National de Demografía y Salud: ENDSA 2008 (La Paz, Bolivia: MSD, Programa Reforma de Salud, INE, and ICF Macro, 2009).
3. MSD et al., Enquesta National de Demografía y Salud: 179.
4. MDS et al., Enquesta National de Demografía y Salud: table 9.6.
5. Steven A. Harvey et al., “Are Skilled Birth Attendants Really Skilled? A Measurement Method, Some Disturbing Results and a Potential Way Forward,” Bulletin of the World Health Organization 85, no. 10 (2007): 733-820.
6. Included women who were currently pregnant but had wanted to prevent or delay the pregnancy.

(April 2010) Paraguay does not seem a likely candidate for rapid fertility decline: The population is poorer, more rural, and has lower educational levels than its neighboring countries. A large percentage of the population speaks Guarani, an indigenous language, rather than Spanish, the official language. Yet despite a large population that is traditionally hard to reach with reproductive health information and services, Paraguay recorded a remarkable increase in contraceptive use and a sharp decline in fertility over the past decade. A recent study of Paraguay’s fertility transition through 2004 documented a fall in the total fertility rate (TFR), or lifetime number of births per woman, from 4.3 in 1998 to 2.9 in the 2001-2004 period, and suggested continued decline because younger women said they wanted fewer children.¹ A new survey seems to confirm that assertion, showing the TFR down to 2.5 children per woman by 2008, a faster decline than projected in the most recent United Nations’ population projection series.² The percentage of married women ages 15 to 44 using contraception increased impressively, from 57 percent to 79 percent between 1998 and 2008.

There is a wide gap in TFRs between the more modern and educated populations and the more traditional population groups. The TFR was down to 2.2 children per woman among urban residents, while it was still 3.0 among rural residents in 2002. Similarly, Spanish-speaking women averaged just 2.2 children, compared with 3.3 among Guarani-speaking Paraguayans. The most dramatic differences were by education: Women with less than five years of education averaged 3.6 children, while those with at least 12 years of education averaged just 2.0 children.

Like many developing countries, Paraguay has seen rapid improvements in the education of girls in recent decades. Enrollment in elementary school is nearly universal, and data from UNESCO show the percentage enrolled in secondary school rising from 59 percent to 68 percent between 1999 and 2002, the most recent year statistics are available. This is well below the regional average of 92 percent, but a marked improvement in just a few years.³

Recent increases in the education of women in Paraguay have been tied to greater contraceptive use up through 2004. However, the 2008 survey shows that acceptance of contraceptive use has spread among all education levels. Even among women with less than three years of formal education, 72 percent used a contraceptive in 2008, compared with just 36 percent in 1998 (see Figure 1). Just as telling, the gap in contraceptive use between urban and rural women disappeared by 2008. While there are still clear rural and education differences in actual childbearing, it seems likely that those differences will abate further in coming years.

Figure 1
Increasing Contraceptive Use Among Paraguayan Women, 1998 to 2008

Source: El Centro Paraguayo de Estudios de Población et al., Paraguay Reproductive Health Survey 2008, CD-ROM.

Low Fertility in the Southern Cone

With the low and declining fertility documented in these new surveys, Paraguay joins its more urbanized and prosperous neighbors in South America’s southern cone in forming a low-fertility zone.

Brazil saw impressive declines in fertility since the mid-1990s, from about 2.5 children per woman to 1.8 according to the National Institute for Geography and Statistics (IBGE)—possibly the lowest in South America. Brazil’s fertility decline has been attributed to a shift in preferences for fewer children that some analysts tie to popular nighttime soap operas, or telenovelas, that reinforced the positive image of small families.⁴ Effective contraceptives are widely available, with sterilization (male and female combined) the most common method.⁵

Argentina has had relatively low fertility—below 3 children per couple—for decades, but the TFR only recently dropped close to the replacement level of 2.1 children per women (see Figure 2). Fertility has tracked even lower in Uruguay and Chile. Uruguay’s TFR is now at the two-child level, according to official birth statistics. Chile’s fertility declined close to replacement level by 2000, and is now about 1.9. While we do not have recent surveys of contraceptive use from these other countries, there is evidence that contraceptives are widely available and accepted.

Figure 2
Fertility Decline in Southern Cone Countries, 1990-95 to 2010

Sources: UN Population Division, World Population Prospects: The 2008 Revision; UN Statistics Division, UN Demographic Yearbook, 2006; Ministério da Saúde e Centro Brasileiro de Análise e Planejamento, Pesquisa Nacional de Demographfia e Saúde da Criança e da Mulher, 2006; El Centro Paraguayo de Estudios de Población et al., Paraguay Reproductive Health Survey 2008, CD-ROM.

Fertility Higher in Other South American Countries

While fertility rates have fallen throughout South America, they have not fallen as far in the more northern countries, especially in Bolivia, Ecuador, and Peru. Bolivia has among the region’s highest fertility, with a TFR of 3.5 according to a 2008 Demographic and Health Survey. Bolivia, with its large indigenous, non-Spanish speaking population, has the characteristics of a high-fertility country: lower educational levels, high poverty levels, a large rural population, and low use of modern contraceptives. The UN Population Division and the Center for Latin American and Caribbean Demography (CELADE) project modest fertility decline in Bolivia in the next two decades.

Fertility is expected to fall more rapidly in more economically developed and more urban countries of South America, including Colombia and Venezuela. They are projected to join the southern cone countries with replacement level fertility over the next decade. The major uncertainty is how fast fertility will fall, especially in areas that have lagged behind in economic and social development. The surprisingly rapid fertility decline in Paraguay shows how quickly things can change when young couples embrace the idea of smaller families and actively limit the number of children they have.

Mary Mederios Kent is senior demographic editor at the Population Reference Bureau.

References

1. Kanako Ishida, Paul Stupp, and Mercedes Melian, “Fertility Decline in Paraguay,” Studies in Family Planning 40, no. 3 (2009): 227-34.
2. El Centro Paraguayo de Estudios de Población et al., “Paraguay Reproductive Health Survey, 2008,” CD-ROM (Atlanta: Centers for Disease Control and Prevention, 2009).
3. UNESCO, Institute for Statistics Data Centre, accessed at http://stats.uis.unesco.org,  on March 26, 2010. These figures are for the gross enrollment in secondary schools: the total number of secondary students of any age divided by the number of children of secondary-school age.
4. Vilmar E. Faria and Joseph E. Potter, “Television, Telenovelas, and Fertility Change in Northeast Brazil,” in Dynamics of Values in Fertility Change, ed. Richard Leete (Oxford, England: Clarendon Press, 1999); and Eliana La Ferrara, Alberto Chong, and Suzanne Duryea, “Soap Operas and Fertility, Evidence From Brazil” (Inter-American Development Bank, 2008), accessed at www.iadb.org/res/files/WP-633updated.pdf,, on April 6, 2010.
5. Ministério da Saúde e Centro Brasileiro de Análise e Planejamento, Pesquisa Nacional de Demografia e Saúde da Criança e da Mulher, 2006, accessed at http://bvsms.saude.gov.br/bvs/pnds/index.php,, on April 1, 2010.

(August 2008) Fertility has declined significantly throughout the developing world, and in Latin America total fertility rates (TFRs) have declined by 50 percent over the last three decades, from 5.0 births per woman in 1970 to only 2.5 today.¹ Service providers have achieved many family planning and reproductive health (FP/RH) successes in Latin America, most notably the increase in modern contraceptive prevalence rates to 64.5 percent of sexually active women in 2007.² These successes have led international health and development agencies to focus their attention on other regions that have yet to show similar improvements in reproductive health.

The successes in Latin America however, mask a great deal of regional variation. In countries such as Bolivia, Guatemala, and Haiti, total fertility rates, a measure of the average number of children a woman will have over her lifetime, are still nearly 4.0 or higher.³ Furthermore, in these countries, between 22 percent and 32 percent of women who do not desire another child or want to space their births still have no access to family planning services.⁴ Within the Latin American countries that have experienced substantial declines in fertility, there are sub-populations and regional pockets characterized by high fertility and lack of access to FP/RH services. Among those with the most limited access to basic reproductive health services are people living in the poorest and most remote communities—on the frontiers of lowland tropical forests like the Amazon and indigenous people living far beyond forest frontiers.

An analysis by the authors of regional and provincial data from Demographic and Health Surveys (DHS) show continued high fertility in the Amazon regions of several countries including Bolivia, Brazil, Colombia, Ecuador, and Peru (see Table 1). Total fertility rates are in most cases substantially higher than national rates: In Ecuador, fertility is higher in the Amazon than in any other region of the country. These averages mask substantially higher fertility in rural areas of the Amazon, which are almost unrepresented in DHS data. The DHS data for the Brazil North region, for example, contains only 14 rural observations. The DHS data from rural Amazon provinces of Colombia report no data. And fertility surveys from Ecuador do not report disaggregated rural data for the Amazon.

Table 1
Total Fertility Rates (TFR) for Select Areas of the Amazon Latin America

Note: The total fertility rate (TFR) measures the total number of lifetime births a woman would have given current birth rates.
Sources: The TFRs for Bolivia, Brazil, Colombia, and Peru were obtained from Demographic and Health Survey (DHS) reports. The TFRs for Ecuador were obtained from the report for ENDEMAIN—a DHS-type survey conducted periodically by MEASURE and CEPAR.

Data on modern contraceptive prevalence rates for these same regions also reveal low rates of modern contraceptive use (see Table 2). The little rural data available suggest that contraceptive prevalence rates (CPR) among sexually active women of reproductive age are under 50 percent for the majority of the Amazon.

Table 2
Modern Contraceptive Prevalence Rates (CPR) for Select Amazon Tropical Forest Areas of Latin America

^a Rural North Region contains only 14 observations.
^b Urban areas only.
^c Women in unions. Rural and urban could not be disaggregated for Ecuador Amazon.
^d Data not available.
Note: The total fertility rate (TFR) measures the total number of lifetime births a woman would have given current birth rates.
Sources: The CPR for Bolivia, Brazil, and Peru were calculated from Demographic and Health Survey (DHS) data and included women ages 15 to 49 who were currently married or in consensual union, and unmarried sexually active women. CPR for Columbia and Ecuador were obtained from the DHS and ENDEMAIN reports respectively.

Indigenous populations in lowland Latin America tend to be particularly underserved by health providers for many reasons, including cultural barriers, language, and accessibility. Available studies among these indigenous populations indicate TFRs from 7.0 to 8.0.⁵ Some researchers have argued that fertility rates among these indigenous women remain high because of a strong desire to have large families. However, survey data from indigenous women in the Ecuadorian Amazon contradict this argument, and indicate that approximately 50 percent do not want another child. Yet 98 percent of these women were not using a modern contraceptive method.⁶ While some might argue that the populations are too small to warrant attention from development agencies, the social and environmental implications of this growth are of great interest to the environmental community.

Conservation, Population, and Indigenous Peoples

Latin American tropical forests, including the Amazon basin, contain the world’s greatest concentration of biodiversity and play a critical role in climate change. More than two decades of conservation efforts have sought to decrease rates of deforestation in Latin American tropical forests. Despite these efforts, estimates of Amazon deforestation from 2002 to 2004 were near their highest levels since monitoring began in 1988, with an average of 2.5 million hectares annually.⁷ After three years of improvement, recent reports of deforestation during the last months of 2007 and first months of 2008 were the highest ever recorded for the wet season.⁸ The causes of this deforestation include underlying forces such as crop prices, land and forestry policies that encourage logging, and weak enforcement institutions at the national and global level. These forces drive local-level human activities such as agricultural expansion, timber extraction, and infrastructure growth that directly result in forest loss.⁹

In response, conservationists are seeking new strategies and new partners to protect the largest remaining tracts of tropical forest. Indigenous lands now encompass the single largest category of protected area in the Amazon, and 20 percent of the Amazon is now under the permanent rights of indigenous people. Indigenous lands are now touted as a critical barrier to future deforestation.¹⁰ Many of the largest conservation groups now work with indigenous groups, and international development agencies are beginning to finance conservation projects that work with indigenous groups. Central to the conservation objectives of these programs is the improved well-being of indigenous populations. Thus, indigenous communities and conservation organizations together should assess how demographic change will impact the health and livelihoods of indigenous households and the ecosystems in which they live.

The direct linkages between fertility and deforestation are often thought to be obvious (for example, more people leads to larger farms and thus more deforestation). In reality, however, the relationship between high fertility and land use has not been found to be as clear as is often stated. Research on the causes of tropical deforestation has found population growth to be a consistent underlying factor contributing to deforestation, though this growth is often due to migration and settlement of new colonists rather than high fertility rates.¹¹ A more established link is the cyclical relationship between fertility and poverty, in which high fertility and poor maternal and child health outcomes are both symptoms of poverty and contributors to impoverishment, and affect the way people use, conserve, or overuse resources.

Changes in indigenous livelihoods are already evident at the household level, where increasing wage employment, market-based agriculture, and migration to cities have begun to replace traditional livelihoods of subsistence agriculture, hunting, fishing, and gathering of forest products. Less understood, however, are how demographic changes might affect the communal management groups that have traditionally managed agricultural lands, rivers, and forests. These communal management groups, for example, often make decisions regarding who can hunt, when they can hunt, and what they can hunt on indigenous lands. Now, these groups must confront the added challenges of greater external pressure from the growing population surrounding indigenous lands as well as greater internal pressure from their own growing populations.¹²

Role of Conservation Organizations

Over the last several years, a few conservation organizations have piloted projects that address the complex links between reproductive health, poverty, and conservation. These projects have adopted an integrated approach to community development that has been termed the Population, Health, and Environment (PHE) approach. The central tenets to this approach are first, that in many remote areas, conservation organizations are among the only institutions providing communities with development assistance; and second, providing men and women with health services and the opportunity to plan their families is beneficial both to the well-being of households and to the long-term sustainability of the forest, fishing, and hunting resources they manage.

The Population Reference Bureau’s PHE Program has been instrumental in developing the PHE approach by providing information to conservation organizations on the links between population, health, and environment, building the capacity of individuals and organizations to work on these cross-cutting issues, and encouraging institutions to form professional networks to share PHE experiences and lessons.

This approach, however, has principally been piloted in Africa and Asia because of the greater need for FP/RH services in these regions and, in part, because of the perception that most Latin American countries no longer need international assistance to provide FP/RH services.¹³ Furthermore, most Latin American ministries of health are just beginning to develop the capacity to procure and manage supply chains for contraceptives and have yet to focus on distribution of services to remote areas.¹⁴ Thus, despite the existence in Latin America of high-priority conservation areas with high unmet need for family planning, there is little indication that the next generation of PHE projects will focus on the unmet need of remote populations in Latin America.

Nonetheless, people in lowland areas of Latin America show an interest in and need for FP/RH services, and conservation organizations are among the few institutions building relationships with indigenous groups. There is, therefore, great opportunity for collaboration between health care providers and conservationists to better the welfare of indigenous peoples, a group typically underrepresented as benefactors of development in the Americas. Responding to this opportunity will require the creativity and commitment of the PHE community and the identification of new priority areas, new partners, and new sources of funding.

Jason Bremner is program director for Population, Health, and Environment at the Population Reference Bureau. Audrey Dorélien was a 2008 Bixby intern at PRB.

References

1. 1. United Nations Department of Economic and Social Affairs, World Population Prospects: The 2006 Revision (New York: United Nations, 2007).

1. 1. United Nations Department of Economic and Social Affairs, World Contraceptive Use 2007 (New York: United Nations, 2007).

1. 1. United Nations Department of Economic and Social Affairs, World Population Prospects: The 2006 Revision.

1. 1. United Nations Department of Economic and Social Affairs, World Contraceptive Use 2007.

1. 1. Kendra McSweeney and Shanha Arps, “A Demographic Turnaround—The Rapid Growth of Indigenous Populations in Lowland Latin America,” Latin American Research Review 40, no. 1 (2005): 3-29.

1. 1. Jason Bremner et al. “Fertility Beyond the Frontier: Indigenous Women, Fertility, and Reproductive Practices in the Ecuadorian Amazon,” Population Environment (forthcoming).

1. 1. Instituto Nacional de Pesquisas Espaciais, Annual Estimates of Deforestation 1988-2007, accessed online at www.inpe.br, on June 5, 2008.

1. 1. Alexei Barrionuevo, “Brazil Rainforest Analysis Sets Off Political Debate,” The New York Times, May 25, 2008.

1. 1. Helmut J. Geist and Eric Lambin, “Underlying Driving Forces of Tropical Deforestation,” Bioscience 52, no. 2 (2002): 143-50.

1. 1. Daniel Nepstad et al., “Inhibition of Amazon Deforestation and Fire by Parks and Indigenous Lands,” Conservation Biology 20, no. 1 (2005): 65-73.

1. 1. Geist and Lambin, “Underlying Driving Forces of Tropical Deforestation.”

1. 1. Jason Bremner and Flora Lu, “Common Property Among Indigenous Peoples of the Ecuadorian Amazon,” Conservation and Society 4, no. 4 (2006): 499-521.

1. 1. John Pielmeier et al., Assessment of USAID’s Population and Environment Projects and Programming Options (Washington, DC: United States Agency for International Development, 2007).

1. 1. Thais Aguilar, Safeguarding the Contraceptive Supply in Latin America in an Era of Donor Phase Out (Washington, DC: Population Reference Bureau, 2006.