Concerns Regarding Conceptual Framework Design and Evidence SynthesisDear Dr.Papageorghiou   We read with interest the article entitled “Towards the Development of a Conceptual Framework of the Determinants of Pre-eclampsia: A Narrative Review” by Elawad et al. The goal of constructing a framework to guide understanding of pre-eclampsia’s complex etiology is commendable; however, several methodological and conceptual limitations warrant attention.   Firstly, although the study is framed as a narrative review, the criteria for study selection, quality assessment, and data synthesis are not described in sufficient detail. Without transparent inclusion criteria or a structured synthesis method (e.g., thematic analysis or realist review principles), the review risks subjectivity and selection bias (1).   Secondly, the proposed conceptual framework is not empirically validated. While narrative reviews can inform theory development, the framework presented appears to rely on selectively cited associations without formal methods such as expert consensus, Delphi methodology, or evidence mapping to support framework domains (2).   Thirdly, the determinants are categorized into biological, social, and health system domains; however, the boundaries between these categories are often blurred in the text. For example, ”low maternal education” could plausibly fall under both social and health system factors depending on interpretation. Clear operational definitions and justification for domain placement are needed to enhance conceptual clarity and reproducibility (3).   Fourth, the review emphasizes social determinants of health but underrepresents recent advances in molecular biomarkers and placental pathophysiology that could refine etiological understanding. This imbalance may limit the utility of the framework for clinical or translational research settings (4).   Lastly, the review does not include a discussion on the potential limitations of the proposed framework or provide guidance for future validation or application. Conceptual models should include an iterative pathway for empirical testing, refinement, and feedback to ensure their long-term utility (5).   In conclusion, while the authors have initiated an important discussion, a more systematic, methodologically rigorous approach to framework development is needed to support its validity and relevance in future research.   Sincerely, Mücahit Furkan BALCI Medical Doctor Torbalı State Hospital, Izmir, Turkey mucahitfurkanbalci@gmail.com İbrahim KARACA Associate Professor Bakırcay University Cigli Research and Education Hospital, , Izmir, Turkey dribrahimkaraca@gmail.com References: (1) Greenhalgh T et al. Narrative review: methods and reporting. BMJ. 2018; 348:g132. (2) Nilsen P. Making sense of implementation theories, models and frameworks. Implement Sci. 2015;10:53. (3) Miles MB, Huberman AM. Qualitative Data Analysis. Sage; 1994. (4) Redman CW, et al. Placental stress and pre-eclampsia: a revised view. Placenta. 2014;35 Suppl:S38–42. (5) Jabareen Y. Building a Conceptual Framework: Philosophy, Definitions, and Procedure. Int J Qual Methods. 2009;8(4):49–62.