Victoria has identified 281 baby deaths over five years that had preventable "contributing factors", including inadequate medical care.
It comes after two reviews identified 11 babies had died potentially avoidable deaths at the Djerriwarrh Health Service in Bacchus Marsh from 2001 to 2014.
The Victoria's Mothers, Babies and Children Report looked at contributing factors in perinatal deaths across the state from 2008 to 2013.
"Contributing factors were identified in approximately five per cent of all perinatal deaths reported," the recently released report said.
"Recurrent themes include inadequate antenatal and intra-partum foetal monitoring, inadequate management of the second stage of labour, and inadequate paediatric management, including advanced neonatal resuscitation."
The report identified 528 preventable factors across 281 deaths.
Perinatal deaths refer to stillbirths and live births with only brief survival.
The Bacchus Marsh deaths sparked lawsuits, and significant staffing and procedure changes at the hospital.
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