In Bolivia, Slow Fertility Decline and Some Improvements in Health Indicators

(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

2010 Total Population (millions) 10.4
2050 Total Population (millions) 16.0
Population Under Age 15 (%) 37
Population Age 65+ (%) 4
Average Number of Births per Woman 3.5
Life Expectancy at Birth (years) 66
Infant Mortality Rate (deaths under age 1 per 1,000 births) 45

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.


  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.