Expectant mothers in part of Inverclyde receive a "second-class service", a sheriff has said in his findings after a fatal accident inquiry.
The sheriff said Chloe's death could not have been avoided
Chloe McIver died while being born at Inverclyde maternity unit in Greenock shortly after it had been downgraded to midwife-led status.
Sheriff John Herald said her death could not have been avoided.
But women in areas served by units without consultants were receiving a lower standard of service, he added.
The inquiry heard that Jane Watt had been due to give birth at Paisley's consultant-led unit.
But with the baby's birth imminent she was taken to her local maternity unit at Inverclyde Royal Hospital in Greenock, which had become a midwife-only centre.
Chloe was born with the umbilical cord wrapped tightly around her neck and died early the next morning.
Although he ruled that the baby's death had been inevitable, Sheriff Herald said it was difficult to avoid the conclusion that women in areas with midwife-only units were getting an inferior service.
Pregnant women in Greenock and the Vale of Leven received a "second-class service" in comparison to those living in the Paisley area, where the specialist Royal Alexandra Hospital is located.
The sheriff voiced "concern" that neither Chloe nor her parents saw a senior clinician over the 22-hour period between her birth and death.
Protest at changes
Earlier this year, the Scottish Women's Convention said mothers should be given a bigger say when changes to maternity services were being planned.
The group said mothers in rural areas in particular were being poorly served by the downgrading of their local maternity units.
Changes across Scotland over the last few years have provoked widespread protest from objectors in places such as Wick and Aberdeenshire.
NHS Argyll & Clyde said it had taken on board the sheriff's ruling and would soon make known to Chloe's parents the findings of an internal inquiry into their daughter's death.
Cathy MacGillivray, director of nursing at the health board, said: "Our sympathies as always are with Chloe's family.
"We have put procedures in place to give families the option of transferring to the Royal Alexandra Hospital in Paisley for terminal care as NHS Argyll & Clyde cannot guarantee that a consultant paediatrician will be able to attend an instance such as the one highlighted in this FAI.
"If the decision of the family is to remain in the community maternity unit they will be fully informed that they will be supported by midwives and not by a consultant paediatrician."
Labour MSP for Greenock and Inverclyde Duncan McNeil said: "Although he has found that this tragic death could not have been avoided, the sheriff's wider comments will make it very difficult for the health board to continue to argue that their reorganisation of maternity services was done in the interests of patient safety."