Victoria's Mothers, Babies and Children Report looked at contributing factors in perinatal deaths across the state from 2008 to 2013.
Perinatal deaths refer to stillbirths and live births with only brief survival.
The report follows two reviews that identified 11 babies who had died potentially avoidable deaths at the Djerriwarrh Health Service in Bacchus Marsh from 2001 to 2014.
"Contributing factors were identified in approximately five per cent of all perinatal deaths reported," the report says.
"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 most common contributing factors for perinatal deaths in the period between 2008 and 2013 were: inadequate intra-partum care and management of specific conditions, inadequate clinical monitoring and inadequate antenatal.
But Jeremy Oats, chair of the Consultative Council on Obstetric and Paediatric Mortality and Morbidity, which produced the report, told SBS that of while 281 deaths were identified as having "potential contributing factors", in only a small number of those cases did the contributing factors result in death.
He said the report highlighted need for improvement but stressed that Victoria's perinatal mortality rate was "one of the lowest in the world".
The report showed that Aboriginal babies were twice as likely to be stillborn or die after childbirth as non-Aboriginal babies.
Other groups with higher rates of perinatal deaths included babies of women born in North Africa, the Middle East or southern and central Asia, and babies born pre-term.
The Bacchus Marsh deaths sparked lawsuits and significant staffing and procedure changes at the hospital.
Read the full report:
