A state government report that dwarfs the recent baby death scandal at Bacchus Marsh Hospital reveals 281 deaths between 2008 and 2013 involved "contributing factors" including inadequate clinical monitoring, misinterpretation of tests and delayed caesarean procedures.

Other factors included insufficient care during pregnancy, inadequate management of specific conditions, and "resuscitation factors".

A small proportion of the deaths were also considered to involve "family neglect or ignorance" such as parents not attending medical appointments, but exact numbers in this category were not disclosed.

Professor Jeremy Oats, a leading obstetrician and chair of the state government committee that produced the report, said although the contributing factors were concerning, they did not necessarily cause the deaths.

He said the committee concluded that about one in 10 deaths (about 28 over the six years) involved "significant preventable" factors on a par with those found responsible for the 11 avoidable deaths at Bacchus Marsh hospital between 2000 and 2014. The report does not disclose in which hospitals the estimated 28 deaths occurred.

The 281 deaths in the report include stillbirths (from 20 weeks gestation) and infants who died within 28 days of birth. They also include nine of the 11 preventable deaths at Djerriwarrh Health Service in Bacchus Marsh.

Professor Oats said "significant clusters" of deaths at other hospitals had not been found, however he acknowledged that some services had results that warranted investigation.

The report showed that between 2009 and 2013 babies were more likely to die at Bacchus Marsh, Casey Hospital in Berwick, Frankston Hospital, the Northern Hospital in Epping and Sunshine Hospital.

The report, "Victoria's Mothers, Babies and Children 2012 and 2013", also looked at how many babies without congenital anomalies fell ill within five minutes of birth. This measure, known as the "Apgar score", is an indicator of potentially poor care.

Based on this data, the "least favourable" hospitals were Yarrawonga, Mildura, Warrnambool, Ararat, Geelong, Bendigo, Box Hill, Colac, Wonthaggi, Kerang, Echuca and Traralgon.

Kathryn Booth, head of medical negligence at Maurice Blackburn Lawyers, said the data was "very alarming" and suggested Bacchus Marsh "was far from the only hospital in Victoria that was struggling to provide adequate care for expectant mothers and their babies".

"Many of these deaths could have and should have been avoided. Similar issues were identified among the catastrophic failures at Bacchus Marsh Hospital that resulted in multiple babies dying or sustaining lifelong injuries," she said.

Professor Oats said parents of the 281 babies are very likely to have been told of the problems in their baby's care as part of the open disclosure process in Victorian hospitals which encourages transparency about medical errors and adverse events.

A spokeswoman for Victorian Health Minister Jill Hennessy said the government had set up new committees to review every perinatal death in regional areas and that an autopsy service had been established at the Royal Women's Hospital to examine all perinatal deaths across the state.

There were about 78,000 births in Victoria in 2013.

Hospitals of concern

• Albury Wodonga
• Geelong Hospital
• Casey Hospital Berwick
• Frankston Hospital
• Northern Hospital Epping
• Sunshine Hospital
• Box Hill Hospital
• Mildura Base Hospital
• South West Healthcare Warrnambool
• Echuca Regional Health
• Swan Hill District Health
• Bass Coast Regional Health
• East Grampians Health Service Ararat
• Kerang District Health Service
• Colac Area Health
• Yarrawonga District Health Service 

Source: Victoria's Mothers, Babies and Children 2012 and 2013.